Patient Wanders Away From Bed, Found Dead 17 Days Later

This apparently happened at San Francisco General Hospital recently.  A disoriented 57 y/o woman was admitted with a bladder infection and given orders: “NEVER leave patient unattended.”  The patient wanders away from bed repeatedly.  One day she disappears, and a search is reportedly undertaken.  17 days later she is found dead in a stairwell.

Now, an investigation reveals that the patient was left unattended by the nurses.  When a search was ordered, it was not systematic, and the stairwells were not searched by sheriff’s deputies responsible for security.  A medical researcher even reported seeing an unconscious woman an a stairwell four days before she was finally found.

You can read all about the story from a local newspaper, SF Gate: http://bit.ly/Ln1qkB    which gives all the details of the sordid story.  It is not stated, however, but I think it may be true, that the hospital is overworked and understaffed, and that contributed to the disaster.  I doubt that the nurses deliberately ignored the order to keep the patient under constant observation.  More likely they were so overworked that they overlooked the need to relieve staff members assigned to watch the patient when they were called away.

Likewise, the sheriff’s deputies who were assigned to hospital security were understaffed and working overtime.  They had not received a comprehensive search plan and thus missed some parts of the hospital.  The hospital administration was trying to supplement or replace the deputies because they were not providing adequate security.

Under these circumstances, a disaster like this is much more likely.  Comprehensive planning must always take into account the risks associated with shortages and poor planning, partial implementations, deliberate personnel problems caused by administration feuds, and so on.