practice partner
Patient Safety
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
Extent of illness
in morbidly
obese patients
may not be
appreciated
photo: istockphoto.com
A
ever addressed appropriately, even though it
review of the death of a 25-yearpersisted and required multiple ED visits.
old man has prompted the Chief
The PSRC recommended to the Ontario
Coroner’s Patient Safety Review
Hospital Association and Ontario Medical
Committee (PSRC) to remind phyAssociation that it develop and/or enhance
sicians of the challenges in clinical assessment of
existing processes to ensure
morbidly obese patients, which
that appropriate primary care
may lead to a risk of under-apfollow-up is arranged followpreciation of the severity of their
It is not clear if this ing ED visits, particularly for
condition.
The 177 kg patient, with
chronic constipation patients with repeat ED visits
for the same problem.
a BMI of 57.8, died of fecal
was ever addressed
Integrated service provision
peritonitis due to a presumed
appropriately,
even
for individuals seen mulcolonic perforation while
waiting for his doctors to find
though it persisted tiple times in the ED for the
same issue is essential, stated
a bed in another hospital that
the PSRC. Even though the
could accommodate his size.
patient presented repeatedly to
The individual had a history
the ED with severe chronic constipation, it
of severe chronic constipation with mulwas not clear that he was receiving care from
tiple ED visits; however, there was a lack of
a primary care provider coordinating the inevidence to demonstrate if there was follow
vestigation and management of his condition.
up in the community for these conditions. It
“It is important to pursue procedures for
is not clear if this chronic constipation was
Issue 3, 2015 Dialogue
43