Organizations and Accidents

Abstract

A construction worker falls from the top of a scaffold and is transported by EMS to an Emergency Department. At the time of admission, the Emergency Department is understaffed and many patients are waiting to be evaluated. Due to the hectic workflow, the only available physician performs only a very basic clinical check before heading for the next patient. Because the initial clinical findings suggest serial rib fractures, the physician orders a CXR. At the Radiology Department, the CXRs are swapped and the patient returns to the Emergency Department with the wrong images. Because the patient carries the CXRs and because the family name on the film is identical to the patient’s name, no suspicion arises that the films could be wrong. Neither first name nor date of birth is verified. The actual severity of his injuries is misjudged because an inexperienced student nurse accompanies the patient, and because vital monitoring (pulse oximeter) is not immediately available. When the patient’s clinical status deteriorates, the physician cannot correlate the symptoms with the normal radiological findings. Because the CXRs show no pathology, the resident neither crosschecks the radiological findings by repeating the clinical examination (e.g., chest auscultation) nor reexamines the CXR (e.g., verifying the patient’s name); instead, he orders pain therapy with morphine, which worsens the clinical situation. It is only after a successful intubation that new clues emerge (e.g., decreased breath sound, subcutaneous emphysema) which point to a pneumothorax. The situation is complicated by the fact that controlled ventilation precipitates a tension pneumothorax which rapidly develops into cardiac arrest. Moreover, the defibrillator that the code team carries is a new model with which nobody is really familiar. The delay of the first shock is caused by the conscious effort to identify the necessary steps for action.