What went wrong in first U.S. Ebola case--and how to fix it

A Texas hospital must make several changes and improvements to avoid the mistakes that led to a patient with Ebola infecting two nurses prior to his death, according to an independent report released by Texas Health Resources, the hospital's parent company.

More than a year ago, Liberian national Thomas Eric Duncan became the first person diagnosed with Ebola in the United States, dying in Texas Health Presbyterian shortly thereafter. The hospital came under fire for numerous mistakes and oversights during the process, such as sending Duncan home initially after failing to recognize his symptoms and failing to isolate him while he was contagious. Before Duncan's death, two of his nurses also contracted the virus. While both later recovered, one, Nina Pham, filed a lawsuit against Texas Health Resources, claiming privacy violations.

The company convened an expert panel, chaired by Denise Cortese, M.D., emeritus president and CEO of the Mayo Clinic, which issued recommendations for correcting Presbyterian's mistakes. Several strategic errors contributed to Duncan's initial misdiagnosis and discharge, according to the report, including lack of physician oversight in the emergency department, prioritizing patient satisfaction over outcomes and lack of interprofessional cooperation.

Presbyterian, as well as other hospitals dealing with similar scenarios, can safeguard against any such future incidents through several concrete actions, according to the panel's recommendations, including:

  • Developing and implementing plans to strengthen cooperation between doctors and ED nurses
  • Negotiating a new contract with the ED physician group that serves the hospital
  • Implementing an emergency preparedness plan throughout the system
  • Standardizing the response to infectious disease scenarios to align system protocols and reduce infection risks

The health system has already begun implementing system-wide emergency protocols based on best practices from high reliability organizations, and will conduct comprehensive drills twice a year, Texas Health said in a statement.

"We recognize the importance of strengthening our preparedness for public health emergencies, whether they involve the rare occurrence of a serious infectious disease or the more frequent disastrous weather events that we experience in North Texas," said Jeffrey Canose, M.D., chief operating officer and senior executive vice president for Texas Health. "We're committed to improving how we prepare, rehearse and respond to these events and have undertaken the necessary work to implement national best practices at Texas Health."

To learn more:
- read the panel's report (.pdf)
- check out the recommendations (.pdf)
- here's the statement