Thomas Duncan's Case Study - Ebola Virus

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Throughout Duncan’s Ebola Virus Event Expert Panel Report, multiple system failures are clearly identified. The case of Mr. Thomas Eric Duncan was a catastrophic event that created fear on American families, especially the Dallas residents, the health care community and the staff of Texas Presbyterian Hospital. This tragic story still displays the magnitude of harm that can be inflicted not only on one individual but to an entire community when the health care systems fails to provide safe, efficient, and timely care, particularly in a case of Ebola virus.

The Emergency Department has an important role in protecting the entire health system and the community. In the case of a missed diagnosis of Ebola Virus Disease (EVD) like during Mr. Duncan’s first Emergency Department visit, the ER failed and put multiple people at harm ultimately leading to a timeline of harmful events, including the infection of two other nurses. (Cortese, Abbott, Chassin, Lyon, & Riley, 2015).

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An obvious system failure that created a domino effect was the omission of the nursing assessment which identified that he had recently traveled from Africa. This information was documented in the patient’s record however, it was not communicated verbally to the physician as directed by a prompt in the EHR. (Cortese et al., 2015). This error showcases how dangerous a lack of communication and interprofessional collaboration between physicians and nurses can be.

Although it is not the RN’s responsibility to diagnose a patient, there are pertaining health assessments that should trigger a higher level of concern; when a patient comes in to the ER with chest pain, there is quick triage and work up for myocardial infarction, sudden onset unilateral weakness leads to a workup for stroke. Recent travel to any country in Africa plus complaints of gastrointestinal symptoms should trigger concerns for communicable or infectious diseases, like malaria, cholera, dengue and although rare in the US, Ebola virus. Therefore one can say there was a lack of knowledge among the nursing staff by not flagging this as a potentially serious case and not informing appropriate care team providers. Training on the Ebola Virus response with a competent knowledge of risk assessment and patient treatment was not made a priority and the clinical team was not prepared to handle what was about unveil.

Even if the physician failed to receive a verbal warning about the recent travel history, the assessment had been placed in the chart, therefore inadequate review of data as well as failure to re-evaluate relevant clinical information can be identified as system failures. When Mr. Duncan seemed to deteriorate, as his temperature elevated and his Systemic Inflammatory Response Syndrome Score increased, possibly raising concerns or sepsis, another red flag should have been raised, and reevaluation, further assessment, and testing should have been done to rule out other differential diagnosis but no action was taken, and ultimately he was discharged home.

The nurse who identified the increase in score did not verbalized this to the appropriate care team, the score representing a high risk in terms of Systemic Inflammatory Response Syndrome went unnoticed and unattended to, and again we can see failure of communication between interprofessional members leading to further errors and consequences.

Later into this tragic event we also see confusion, lack of training and knowledge about what protective standards to follow and who would provide the most up-to-date guidance on managing infection control and personal protective equipment related to the care of Mr. Duncan, leading to the infection of two nurses and placing many others at risk. (Cortese et al., 2015),

We know that ultimately all failures led to the death of Mr. Duncan and the infection of two other nurses who cared for him. After analyzing these mistakes it’s surprising that other staff members weren’t infected, considering the number of professionals that were in some form of direct or indirect contact with Mr. Duncan either on his first or second visit to the hospital.

For an institution to provide care as a high-reliability organization (HRO), staff must carry a culture of safety and provide safe, timely, effective, efficient, equitable and patient-centered care. (Oster & Braaten, 2016).

Lack of inter-professional teamwork caused ineffective communication and unsafe practices during Mr. Duncan’s care. Inadequate communication processes and over-reliance on the Electronic Health Record (EHR) to convey critical information also led to broken communication that was not time-sensitive. The information entered in the chart was also not used accurately and patient-centered care was not the ultimate goal. Cortese et al. (2015).

Because the dissemination of information on Ebola virus treatment and lack of training and knowledge on appropriate personal protective equipment was not made a priority, adverse events were inevitable, leading to the infection of two nurses and placing many others at risk.

The CDC and larger agencies like the Texas Health Resources learned along with Texas Health Hospital in the management of this case of Ebola virus.

Consequently, aside from the physical implications of this event, the system failures mentioned here led to the feeling of distrust, due to multiple changes in guidelines for identifying possible exposure, as well as stress, fear, and anxiety among health care staff. Although the hospital had a system in place to support staff collectively, Critical Incident Stress Management (CISM) was not effectively used. (Cortese et al., 2015).

It is difficult to judge the staff’s safety culture from analyzing one critical event only, like in the unfolding of Mr. Duncan’s story but one can say that the culture within the emergency department did not appear to be focused on quality and safety care, however, it appeared centered in productivity and time performance.

Oster & Braaten identify the importance of safety culture among staff since it provides for a decrease in organizational errors and increases reliability. (Oster & Braaten, 2016). If the Texas Hospital Emergency Department staff truly carried a culture of safety, their focus would have been on the evidence of risks to the organization, and in that case, the assessment of Mr. Duncan’s recent travel would have been flagged early timely, and possibly an early diagnosis of Ebola.

During Mr. Duncan’s first emergency department visit, the key piece of information that identified his recent travel from Africa was documented in the patient record in some flu assessment section, but however, it was not verbally transferred to the physician as part a prompt in the electronic record.

Inadequate communication processes and over-reliance on the Electronic Health Record to transmit critical information are identified in this case as a major system failure that led to a cascade of harmful events, including the wrongful diagnosis of Mr. Duncan during his initial emergency department visit.

Inadequate review and reevaluation of relevant clinical information even when Mr. Duncan deteriorated, also portrays how red flags were ignored and bypassed, even when his temperature rose to 103F, or when the SIRS score went to level 3 out of 4. Once a diagnosis had been established, no further evaluation was made.

The expert panel report could not identify if the physician had seen these changes in the EHR, but multiple concerns could be brought up here. One can ask; What is a vital piece of information worth, if it’s only being placed in the computer, instead of being used for treating and diagnosing appropriately?

The Emergency Department failed at a clinical level, by not effectively identifying Ebola Virus Disease in a timely, safe manner and not performing like a high-reliability organization.

The 2014 Ebola Virus Case which involved Mr. Duncan and the infection of two other nurses, was the first case of Ebola in the history of health care in the United States. (Weinstock, M. 2014). Mr. Duncan’s case serves as example to institutions across the World, so organizational changes take place, so staff could be prepared for unanticipated and potentially catastrophic events like the one Texas Health Hospital faced.

Based on the system failures that occurred during Mr. Duncan’s first visit to the Emergency Department, and the ongoing treatment challenges after his diagnosis with EVD, other organizations can implement changes and strengthen their ability to minimize errors to prevent future mistakes especially in critical events. Oscar & Braaten identify seven drivers for improving patient safety outcomes in high-reliability organizations. Three of these drivers have direct relation on communication; teamwork and collaboration, communication, and handover.

The Expert Panel through their report recommended that the clinical team’s roles, responsibilities, and culture in the Emergency Department were reviewed to ensure high reliability among the entire team. (Cortese et al., 2015). As HRO’s, team members must achieve four competency domains which are: to know their roles and responsibilities, have ethics and values for inter-professional practice, implement appropriate inter-professional communication, and effective teamwork and collaboration. When staff accomplishes knowledge of these skills, teamwork collaboration is successful, errors are minimized, and patients and families are safe and satisfied with their care.

Texas Health hospital learned from their mistakes and thereafter their electronic health record was adjusted to enhance communication of clinical data between physicians, nurses, and other members of the clinical team. The intuition recognized their mistakes and quickly took action to repair them. (Cortese et al., 2015). This serves as an example of what EHR’s should accomplish and what risks other institutions could be facing if theirs or also lack this kind of communication strategy. EHR’s should not be used as a form of legal documentation only but as assistive tool inter-professional communications.

Finally, institutions should implement and enhance processes like the ones that support high-reliability qualities such as sensitivity to operations, preoccupation with failure, reluctance to simplify, deference to expertise and commitment to reliance. (Oster & Braanten, 2016)


  1. Cortese, D., Abbott, P., Chassin, M., Lyon, G.M., &  Riley, W.J. (2015).  The expert panel report to Texas health resources leadership on the 2014 ebola events.  Dallas, TX: Texas Health Resources Leadership.
  2. Oster, C.A., & Braaten, J.S. (2016). High-reliability organizations: A healthcare handbook for patient safety & quality. Indianapolis, IN: Sigma Theta Tau International
  3. Weinstock, M. (2014). In a crisis, communication matters.(health matters). H&HN Hospitals & Health Networks, 88(11), 10.


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