Poor ED lab tracking and reporting system results in sepsis treatment delay.

This case underscores the need to have reliable systems in place to ensure that EDs have: policies in place fore re-assessing patients at discharge, a procedure for describing how vital signs are assessed prior to disposition and how abnormal findings are addressed, a requirement to document the review of vital signs prior to disposition; a requirement for documenting the rationale for continuing with the planned course of action if the vital signs and lab reports that are subsequently reported show anything that is abnormal. Patient re-evaluation is central to high-quality care and to strengthen the physician's ability to make an accurate and timely diagnosis in the ED setting. It is important to understand the significance of ongoing patient monitoring and reassessment, maintaining reliable diagnostic tracking and reporting systems, managing timely call-back systems, and ensuring that the ED team of staff and physicians are well-trained and oriented to hospital policies, procedures, and technology.