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Child's misdiagnosis and death inspire new patient safety measures

Unfortunately, it sometimes takes the shock of tragedy to inspire reform. This is as true in medicine as it is in politics. In one recent case, the misdiagnosis and death of young boy named Rory has inspired new safety measures designed to prevent Rory's story from happening to any more patients.

Doctors' failure to diagnose Rory properly is a too-common scenario. The young boy was told both by his pediatrician and later an emergency room physician that his stomachache was nothing to be too concerned about. However, the boy died from undiagnosed and untreated septic shock three days after his emergency room visit.

Inspired by the particulars of Rory's story, healthcare providers nationwide are attempting to fill the gaps in patient safety protocol which contributed to his death. Of primary concern are holes in communication. In Rory's case, as in so many others, relevant observations were lost in the transfer of his case from the pediatrician to the emergency room. In addition, critical medical tests were not communicated between various providers.

As a result of this tragedy, new checklists, communication protocols and other patient safety measures are going into effect in cases involving potential sepsis and throughout the patient care system generally. A "Rory's Law" is even being considered. It would most likely center around emergency room communication with parents about their child's condition.

The New York Times recently noted that "For many doctors and nurses, Rory's case resonated because so much of what seemed to go wrong was utterly familiar." And this is precisely why Rory's case is inspiring change nationwide. It is a story that is uniquely tragic for his family, but occurs in various forms every single day.

Source: New York Times, "Death of a boy prompts new medical efforts nationwide," Jim Dwyer, Oct. 25, 2012

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