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An Extraordinary Development: One Medical Center’s Courageous Response to a Well-Publicized Crisis

July 19, 2012
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Why NYU Langone Medical Center’s actions in the face of the Rory Staunton tragedy serve as a model for sentinel-event response industry-wide

Just two days ago, I posted a blog about a New York Times article that had been receiving extraordinary attention. As I noted in my previous blog, that article told the story of Rory Staunton, a 12-year-old New York youth who died this spring of sepsis after cutting open his arm while diving for a basketball in his school’s gym. What happened after Rory fell evolved into a personal and family tragedy; and the complicated details of the story, as reported by Jim Dwyer, a Times reporter who was also a friend of Rory’s family, illuminated for Times readers some corners of the exceptionally complex and complicated urgent and emergent care delivery process, and highlighted, as I opined, some of the canyon-like gaps in clinician-to-clinician communication that exist all across our healthcare delivery system and that can, tragically, play a role in terrible patient outcomes.

One noteworthy aspect of all this was the huge number of online reader comments on the article—over 1,600—and the fact that so many were from physicians, including emergency department (ED) physicians and pediatricians. Some comments were extremely defensive (“We see cases like this every day”), but others were quite thoughtful, with notes very worth reading on how exactly where some of the worst communication gaps are, and how such outcomes might be averted in the future.

Well, to add to the unusual nature of this situation, the hospital involved, NYU Langone Medical Center, yesterday announced significant policy changes around clinical care procedures, as reported in today’s Times. In my blog on Tuesday, I purposely avoided naming NYU Langone Medical Center as the hospital where Rory Staunton had received emergency care, for two reasons: first, out of fairness, since I am not Jim Dwyer, and was not the reporter who broke the original story—thus, obviously, my blogging was based on what I read in the Times article. And second, because I didn’t want NYU to become the focus of my points, which were broad and industry-wide in their scope. As I wrote in my previous blog, creating systems of care processes that will go further towards averting medical errors and communication breakdowns will require concerted effort and ingenuity on the part of front-line clinicians, clinician leaders, and clinical and non-clinical informaticists of all kinds, not to mention quality improvement and other professionals, in patient care organizations nationwide.

But it is wonderful news that the clinician leaders and senior executives at NYU Langone have now responded affirmatively and very actively to this difficult publicity. As Dwyer reports in today’s Times, “In a statement, the hospital said that emergency physicians and nurses would be ‘immediately notified of certain lab results suggestive of serious infection, such as elevated band counts.’ Rory Staunton’s bands, or a type of white blood cell, were nearly five times as high as a normal level. The hospital,” today’s article went on to report, “has developed a new checklist to ensure that a doctor and nurse have conducted ‘a final review of all critical lab results and patient vital signs’ before a patient leaves, Lisa Greiner, a spokeswoman, said in a statement. ‘In the unlikely occurrence that a clinically relevant test is only available after the patient is discharged from the E.D., the patient will be called, and the information will be referred with referring physician,’ Ms. Greiner said.”

This is a very important, and indeed courageous, response to the Staunton tragedy, and I salute the leaders at NYU Langone Medical Center for taking action in the rapid, public way in which they have. It’s courageous because of the public nature of the response. The NYU folks could have tried to do what they could to publicly tamp this down and sweep this under the rug, but instead, they did what should always be done when confronted with a sentinel event (and surely, this counts as a sentinel event): they huddled together to uncover what happened, and how, in a systemic, non-blame-based way, they could fix the underlying systemic issues.

I applaud the leaders at NYU Langone Medical Center for their actions, and hope that not a single other child or adult will die as Rory Staunton did, because of preventable gaps in clinical communication. And I hope that hospital and health system leaders across the country will examine this case study, draw lessons from it, and apply the same kinds of systemic process solutions to this nearly universal set of problems, before they, too, experience their own Rory Staunton tragedies.



Medical community,

Is the issue as simple as making a critical value out of the "band" count. Almost no medical centers have such a critical value.

Was the leukocyte count critical?? What about the neutrophil count? Hard to believe that only the Band count was elevated.

The ER physician ordered tests, and should have reviewed the results before sending the patient home. This should always be the case for simple tests that can be resulted in less that 20 minutes. It is not true of a blood culture that may take days to culture.

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