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For two days, Olive View ER patient wasn't assigned a doctor, memo says [Updated]

November 4, 2010 |  1:42 pm

In a series of mistakes described as a “Swiss cheese” event by a hospital official, a patient recently admitted to Olive View-UCLA Medical Center was not assigned a doctor for two days.

The patient was admitted to the county teaching hospital in Sylmar by an emergency room medical student, who filled out admitting paperwork incorrectly, despite help from an attending physician in the emergency room.

Although a doctor’s name was placed on paperwork, the doctor was never called about the assignment, according to a memo by Dr. Mark Richman, who said he was the attending physician who helped the student with the paperwork. The memo was sent to hospital staff Oct 12.

Richman, the hospital’s patient safety and clinical information technology officer, said the patient “sat for two days, getting medical care, but not under the care of a team, and without documentation in the form of an intern, resident or attending H&P [history and physical] or progress notes.”

“The circumstances leading to this reflect what is known in the patient safety field as a ‘Swiss cheese’ event in which a series of events occurs, each of which bypasses an expected blockade of an error,” Richman wrote.

Richman said the problem may not have been an isolated incident, raising concern that medical students, interns and fellows in other departments at the hospital also might be unaware that admission is often a two-step process.

Richman’s memo did not identify the student, the patient, when the patient was admitted to the hospital, what the patient was being treated for or how the mistake was discovered.

To prevent the incident from happening again, Richman wrote that “several gaps will be plugged,” including ensuring that doctors page the doctor they assign to a patient and train medical students during orientation on how to admit patients.

Richman did not return e-mails or phone calls seeking comment Thursday.

Hospital officials did not return calls Thursday. Carol Meyer, the department’s chief network officer, said department officials were investigating the incident. Michael Wilson, a spokesman for the department, said the incident had not been reported to state regulators and that he could not comment further due to state and federal privacy laws.

[Update 3:25 p.m.: The California Department of Public Health is investigating the incident, according to spokesman Ralph Montano. He said Thursday that he could not release details about their inquiry.]

-- Molly Hennessy-Fiske

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