Last week, an extremely disturbing story of hospital negligence was brought to light. A patient being treated for an infection at San Francisco General Hospital, that city’s main public hospital, went missing on Sept. 21. Despite a search of the grounds by both hospital personnel and sheriff’s deputies, her disappearance was a mystery until Oct. 8, when her body was found in a rarely-used stairwell.
According to press reports, foul play has been ruled out, although no details have been released about the ultimate cause of the woman’s death.
The tragedy provoked outrage among city leaders, healthcare providers and the public and has resulted in a number of investigations. The state health department and the San Francisco police are both investigating, and the mayor’s office has requested an independent review of the hospital’s security and patient safety procedures to be performed by the nearby University of California medical center.
Additionally, both the hospital and the sheriff’s department are conducting internal investigations into exactly how they failed to find the missing woman.
One troubling aspect of the story is that the woman was found on the fourth floor of a fire-escape stairwell, and all of its entry doors were equipped with alarms. Once inside the stairwell, the only way to exit is on the ground floor. It is not clear whether the hospital had security cameras in the stairwell or what other security measures were in place in that area.
The hospital has not said whether any alarm was triggered when the woman entered the stairwell. However, the hospital’s chief medical officer admits it is possible that the alarm went off, but within the busy, noisy hospital, no one noticed.
“There is literature about this phenomenon,” he told reporters. “We have alarm overload in medicine. We have alarms of various types that are intended to be safety measures, but it can be a cacophony of chirps and beeps and you can become desensitized to that.”
The official also told reporters that the hospital has put a number of new measures in place to address the inadequate security conditions, including efforts to combat that alarm overload. Daily sweeps have been initiated in all of the hospital’s stairwells, among other procedures.
For now, the patient’s loved ones, the hospital and the public will simply have to wait for the results of the investigations.
Source: SF Gate, “New measures at S.F. General after patient death,” Vivian Ho, Oct. 12, 2013