Lessons from San Francisco

By: February 18th, 2014 Email This Post Print This Post

One of the stories I have been following very closely in hospital and clinic safety is that of San Francisco General Hospital, a facility that has learned a very difficult lesson in how important it is to have protocols in place to deal with missing patients.

Basically, 57-year-old San Francisco resident Lynne Spalding Ford had admitted herself into the hospital Sept. 19 for treatment of a urinary tract infection. She went missing on Sept. 21 and a hospital engineer found her body on Oct. 8 in a fourth-floor exterior stairwell, which was being used as a fire escape, during a quarterly check of the hospital grounds.

There were obviously many questions as to why it took 17 days to find her body, and ultimately the blame fell on hospital staff, overworked nurses who ignored a doctor’s order to “NEVER” leave her unattended since she was on disorientating drugs. More blame fell on the San Francisco Sheriff’s department, whose deputies searched only 3 of the hospital’s 10 stairwells and didn’t even double check to see what Ford looked like – originally they thought they was looking for a black woman in scrubs when she was actually white in street clothes.

Lastly, several hospital staff were fired or forced to resign because they illegally accessed Ford’s medical records without permission FOUR times.

I could write a book on the rules that were broken here, and you’ve heard them before. I am sure the lawsuits have only begun, and although CMS has done their preliminary investigation you can bet the Joint Commission and OSHA are not far behind.

Take some lessons from San Francisco and apply them to your own facility before it’s too late.


The news stated that the body was discovered and reported to other staff with no action taken days before the official discovery. Is that true?


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