Poor planning, communication lead to missteps in care of Ebola patient.

A panel of experts examining the diagnosis and care of Thomas Eric Duncan, a patient diagnosed with Ebola Virus Disease (EVD) in the United States in 2014, and the cases of two nurses who contracted EVD while caring for Duncan, has unveiled its findings along with recommendations to prevent many of the missteps that occurred during the crisis. While the independent panel was convened at the direction of Texas Health Resources, the parent company of Texas Health Presbyterian Hospital in Dallas, observers and the panel itself note that the findings should help hospitals, EDs, and communities across the country prepare for the next infectious disease event. The expert panel noted that ED personnel relied too heavily on the electronic medical record (EMR) to communicate with other members of the care team, and that important information, such as the patient's travel history, was not prioritized or highlighted in the EMR. Patient satisfaction and other operational objectives took precedence over patient safety during Duncan's ED visit, according to the expert panel's findings. The clinical team failed to pick up on changes in the patient's clinical status, missing an opportunity to re-evaluate Duncan and properly diagnosis him with EVD during his first visit to the ED. Confusion over the roles and responsibilities of local and federal health authorities, and inadequate preparation for an infectious disease event led to missteps. The expert panel suggests conducting practice drills that include all participating organizations, and hospital leaders should consider infectious disease threats as well as other types of disasters.