New emergency department procedures
The following case study illustrates improvements to procedures in the emergency department of a public hospital as a result of a recommendation made by the Commission.
In 2004, the Commission investigated a complaint about a failure by the emergency department to diagnose nerve compression in a person who had been in a car accident and was suffering from neck and arm pain. This investigation resulted in the Commission recommending that, because not all injuries might be picked up on initial examination, a second doctor should check all radiological reports daily. The hospital implemented this procedure.
In 2008, a woman who had fallen off a horse attended the emergency department with pain in her neck and hand. The on-duty registrar examined X-rays and CT scans and reached a view that there was no damage to the woman’s spinal cord and no other obvious injury. The emergency department discharged the woman.
The following day, the doctor in charge of the emergency department reviewed the CT scans, in accordance with the policy requiring a review of radiological reports. His review detected a possible spinal fracture. He rang the woman and told her of the result of his review, and advised her to seek immediate treatment.
The woman then attended another hospital which conducted further CT scans and found that she had sustained a highly unusual injury to the ligaments of her spine.
The woman complained to the Commission that the first hospital had failed to diagnose her injury and had prematurely discharged her.
The Commission investigated this complaint and found that the emergency department had followed correct procedures in attempting to diagnose the nature and extent of her injuries. As was later found by the Commission’s expert, the woman had a very unusual and rare ligament injury, which had been missed by the registrar. The expert commented that this could happen, but was usually addressed through the review of the same radiological reports by another doctor the next day.