A Fatally Broken ER


Woman dies in ER lobby as 911 refuses to help

Click here for a more positive ER story posted on the same day… a UK hospital that used Lean to reduce ER waiting time dramatically… read this and think about the impact that Lean could have…

A very sad story from Los Angeles. I'm still haunted by the 911 tape I heard on the TV news last week. Why would someone have to call 911 from an ER? Because the ER is overwhelmed and backed up and, somehow, they weren't properly prioritizing a dying woman.

A woman who lay bleeding on the emergency room floor of a troubled inner-city hospital died after 911 dispatchers refused to contact paramedics or an ambulance to take her to another facility, newly released tapes of the emergency calls reveal.

Edith Isabel Rodriguez, 43, died of a perforated bowel on May 9 at Martin Luther King Jr.-Harbor Hospital. Her death was ruled accidental by the Los Angeles County coroner's office.

Relatives said Rodriguez was bleeding from the mouth and writhing in pain for 45 minutes while she was at a hospital waiting area. Experts have said she could have survived had she been treated early enough.

Is this a single event at this hospital?

The incident was the latest high-profile lapse at King-Harbor, formerly known as King/Drew. The Los Angeles County Board of Supervisors is investigating claims of recent patient care breakdowns, including Rodriguez's case.

Federal inspectors last week said emergency room patients were in “immediate jeopardy” of harm or death, and King-Harbor was given 23 days to shape up or risk losing federal funding.

There are certainly systemic factors. I won't pretend to know what they are, I wasn't there. There's a basic imbalance between “supply” and “demand” in many hospitals, we have to be able to fix this.

Rather than blaming an individual RN for the problem, the Chief Medical Officer, at least for now, is taking the fall:

Dr. Roger Peeks, the chief medical officer at the hospital, was placed on “ordered absence” Monday, the Times reported.

This is a point I bring up often when talking about problem solving — do we “feel better” that the CMO was blamed? Would that fix any of the systemic problems if he were fired? What if he were thrown in jail?

We have to ask why — why was this allowed to happen? What can we do to prevent it next time? We have to do more than just blaming people.

This article outlines other blaming:

The triage nurse involved has resigned, and the emergency room supervisor has
been reassigned. Additional disciplinary actions could come this week.

More blaming in this article:

At the same time, he said, the preliminary investigation suggests that the fault primarily rests with the nurse who resigned. “I think it's a tragic, tragic incident, but it's not a systemic one.

See, there we go, we have an easy scapegoat, the person who resigned. I'm sure the triage nurse feels horrible about what happened.

“Scores of people” have been fired, according to this article:

Scores of people have been fired, including the head nurse who was involved in that latest incident. The hospital remains under federal investigation.

The board of supervisors is calling for more training, but it has been a challenge. Supervisor Yaroslavsky: “How do you train a person to care?”

But what are some possible causes and root causes other than a “bad employee” or “many bad employees?”

  • Bad triage processes — why is this? Would other triage nurses handled the situation differently?
  • Lack of triage training — why? (possibly unrelated to the ER, but lack of skills was a problem in general there).
  • ER Staffing shortages / lack of funding — why?
  • ER overcrowded — why? Lack of insurance leads people to use the ER for primary care, overburdening employees…. this lead
  • Lack of caring / silo-ed employees, a janitor mopped up the woman's vomit, but didn't stop to help, that “wasn't his job” I'm sure. Why is this? Why isn't there an “andon cord” where ANYBODY can “stop the line” and get immediate priority when they see a crisis?

I'm just brainstorming here. I doubt there's any single “root cause.” It's just mind boggling how stuff like this happens. We need systemic fixes. Hold people (especially leaders) accountable, sure, but don't just blame and find scapegoats.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Mark, I’ll tell you what kills me about this blame game. It hurts everyone. I work in a training function in a major organization and love it when a system problem is blamed on something as inconsequential as training. And the reverse also occurs where the solution to a system problem is identified as training. This introduces new waste in the sytem as everyone is forced through a training session to resolve the issue that could be solved through some simple kaizen.


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