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The other day I wrote about Rory Staunton, the young boy who died from septic shock after his arm was cut during basketball practice. Rory died just days after he was initially diagnosed with the flu by emergency room staff at the NYU Langone Medical Center and was sent home. Within days, Rory’s condition had progressed to the point of no return—he had a full-blown case of Toxic Shock Syndrome and his organs soon failed. Because of the attention that Rory’s story has received, NYU Langone Medical Center recently announced that they are changing procedures, including a checklist that would prevent future similar occurrences.

Hospital records show that just three hours after Rory left the hospital, laboratory tests revealed a high level of cells in his blood infected with bacteria. His parents say that they were not told of the lab report and were unaware of how seriously ill their son was when they took him home that night. In fact, the level of bacteria in Rory’s blood was five times that of the normal level. NYU Langone Medical Center stated that doctors and nurses would be “immediately notified of certain lab results suggestive of serious infection, such as elevated blood counts” since Rory’s death. Furthermore, the checklist will also help to ensure that each doctor and nurse has conducted “a final review of all critical lab results and patient vital signs” before a patient leaves the hospital, and that if a patient leaves before a final report is finished, the patient will be immediately contacted in the case of serious infections or other problems, such as those that Rory experienced.

The Greater New York Hospital Association is leading the initiative since Rory’s death, and includes 55 total hospitals that have developed tactics for early diagnosis of sepsis. Several doctors have stressed that Rory’s case demonstrates that doctors need to keep an open mind when diagnosing patients and not to rely so heavily on their preconceived notions of patients’ ailments without fully hearing a patient’s story and symptoms. Other problems include miscommunication between doctors—in this case Rory’s pediatrician and NYU Langone Medical Center staff. These factors, taken together, can prevent needless deaths. Overall, doctors involved in the initiative and beyond are hopeful that Rory’s death will not be without its lessons for doctors to improve patient safety and care.

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