Elene's Story: The Greatest Reason in the World to Reduce Medical Errors
By Bob Catinazzo
Elene D’orsi-Catinazzo did everything she was supposed to do to save her life when the pain of her injuries became unmanageable. She went to a local hospital’s emergency room three times. Two times, she was sent home with pain killers and instructions to return if things worsened. On the third visit she died.
How could she have died after three emergency room visits in four days?
The toughest thing I have ever had to do in my life was telling my two children (who were 14 and 16 at the time) that their mother had passed away. Words cannot describe the atmosphere in our home that night as we tried to understand why this had to happen to such a vibrant healthy person, in the prime of her life. I can only describe it as the “squirrel in the road syndrome” where I couldn’t decide which way to go; right, left, up, down, etc., who to console; me, Nikki, or Justin. Just a sad chaotic atmosphere.
Elene’s story has taken me over eight years to build up the courage to write. As each year and month have passed since our family lost Elene, I am finally able to manage the pain and emotions that now allow me to put pen to paper. As in all deaths involving medical errors, there are victims, and their stories need to be told.
It was only after a recent deposition that I realized those strong emotions would never go away. As such, the pain, sadness, and regret we all feel when we lose someone we love were on display
during that deposition. Tears I thought I was strong enough to hide were uncontrollable.
During the deposition I was asked one question that opened the floodgate of tears.
“What was it about Elene that drew you to her when you first met?”
The answer to that question is where I will begin Elene’s story.
It was her smile and the positive energy she brought with her into the room that first attracted me to her. My late grandmother (Norma Catinazzo) looked at her for the first time and just giggled. I asked her, “Nanna, why are you giggling?” She replied in her Boston accent: “Bobby, she’s got bedroom eyes.” That she did. She was a natural beauty.
She was beautiful and full of energy; and fun-I can tell you that. Based on her educational background in both Physical Education-Human Performance (Bachelor of Science Degree) and Food Science and Nutrition (Master of Science Degree), she was always in great physical shape.
Elene came from an outstanding family. Her mom (Irene D’orsi) and Dad (Nicholas D’orsi) were tremendous role models who created a home environment filled with love surrounded by many family-oriented rituals. I am grateful to have had our children grow up in that environment; they love their Yia Yia and Papou unconditionally.
The strong family life Elene grew up in clearly defined who she was as a person. Yes, she was many things to many people in her life: a daughter, girlfriend, wife, cousin, aunt, friend, co-worker, etc., but the one title that truly defined how Elene impacted this world was “MOM.”
Who she was is nicely articulated in this article written in a Glastonbury CT School system newsletter published following her death, which read: “Within the Glastonbury Public Schools, there are people who quietly dedicate themselves to our children and school system. The contributions of the classified staff go beyond the basics of job descriptions and work procedures. With open minds they help teach values, nurture and often bond with children who struggle in the school environment. We can easily recognize and thank everyone among us, but sadly can only pay tribute to the ones who have passed away. Elene Catinazzo was a fun-loving, vibrant, kindhearted, hardworking piece of our pride puzzle. We think of her often and miss her every day.”
She was a mom to every kid she came in contact with. More importantly, she was the driving force in both Nikki and Justin's lives. I marveled at all the things she did as a "stay at home mom" while I spent a lot of time traveling the country as a DEA Special Agent.
All the activities she juggled alone: homework, cheerleading, karate, soccer, softball, hockey, baseball, and basketball, to name a few, were a testament to her gold medal status as a mom. I might add, she did all this with no family assistance around (due to our job-related relocation required of our family every five years).
Elene was like most DEA wives; she sacrificed her career to stay home and raise our kids. Based on her strong "D'orsi grown" family life, she "hit the ball out of the park" in her role as a mom. She fought tirelessly for both of our kids and took advantage of the many school services available to them to assist in their academic success. Services that became very important to both of them after her death.
There is one thing her death taught me: No job is more important than your family. In the end, all you have is a wall full of plaques and an agency or company that replaces you the minute you walk out the door, no matter how good an employee you were. Sometimes, our regrets in life lead us towards becoming a better person in the end.
For that reason, I write this story.
On 12-07-2012, while on a weekend retreat in Vermont, Elene had an unfortunate slip and fell on some ice while exiting a hot tub. Throughout the rest of her stay in Vermont, she struggled with much pain in the rib area.
Upon returning home on or about 12-11-2012, she sought medical attention from her primary care physician, who subsequently diagnosed her injury as three broken ribs.
On 12-15-2012, after going through most of the week in pain, my daughter (Nikki) drove her to the emergency room at a local hospital, where she was treated and diagnosed for the three broken ribs. She was eventually released from the Emergency Room and instructed to take Percocet as prescribed for pain and schedule a follow-up visit with her primary physician. She was also provided with written instructions to seek medical attention immediately if she experienced the following symptoms: shortness of breath, such as difficulty breathing or wheezing, and showed no improvement in the next few days, and if side effects from taking Percocet developed, such as: rash, difficulty breathing, or severe upset stomach.
It was becoming very obvious that this was going to involve a long recovery.
According to an October 2012 newsletter published by the Mayo Clinic, rib fractures are among the most common bone breaks in older adults. While there's no direct treatment for fractured ribs that remain in alignment, medical care is still essential to avoid serious complications.
Rib bones moved out of alignment can cause life-threatening complications, including punctures and damage to the lungs and other critical blood vessels or organs. According to one study, about 19 percent of older adults who sustained fractures of three or four ribs died from complications.
While rib fractures from mild or moderate trauma or repetitive movement may seem less severe, they are still painful and can lead to severe complications. Pain often occurs with deep breathing. When patients can't breathe deeply or cough, the risk of pneumonia increases. About 30 to 35 percent of people over 65 with rib fractures contract pneumonia.
Other serious complications can occur with fractures due to mild to moderate trauma. Lung bruising and swelling, bleeding into and around the lungs, or a collapsed lung require prompt medical attention. These complications may require the insertion of a chest tube or other surgery, blood transfusion, or artificial ventilation. Emergency care may be needed for light-headedness, shortness of breath, and significant chest pain, particularly if the condition worsens.
On the morning of 12-17-2012, the warning signs began to surface. Elene advised me that she was still in a lot of pain and was experiencing numbness in her neck and right arm and difficulty breathing. She was visibly wheezing and displaying shortness of breath episodes.
Based on the written instructions provided to Elene previously instructing her to return if conditions worsened, I transported her back to the emergency room as things were definitely getting serious.
Upon our arrival to the ER, we were informed that the hospital was busy and was experiencing a shortage of examining rooms to accommodate patients; however, a room was provided after waiting for some time.
Elene was eventually examined, and for some reason, most of the attention she received focused on her neck pain. She was subsequently diagnosed with a cervical strain (which the doctor attributed to her sleeping awkwardly while overcompensating for her rib pain) and provided muscle relaxers. According to Elene, the muscle relaxers relieved the neck numbness she was experiencing; however, she was still experiencing severe rib pain and shortness of breath.
As we waited in the examination room for some time, I became frustrated. I asked the Physician's Assistant (PA) if Elene needed to stay for further testing regarding the excruciating rib pain she was still experiencing (ten days after the fall). The PA advised me that he would check with the doctor and let me know.
The PA returned to the examination room and asked Elene how she was doing. Elene informed the PA that her ribs were hurting badly, but the neck numbness was better.
The PA advised Elene that the rib pain was to be expected, due to the three fractured ribs, and the doctor was discharging her with the instructions to go home and continue to rest. He then released her from the emergency room without further testing.
As in the previous visit, Elene was provided with written instructions to immediately seek medical attention if she experienced severe or increasing pain?!
As we traveled home, both Elene and I were frustrated that no further testing of the rib injury occurred. For some reason, the doctor and PA seemed to pay more attention to the strained neck and just chalked up the rib pain as a necessary evil in her recovery. We put our trust in the medical professionals, figuring they knew what was best.
When we go to the hospital for treatment, we hope to come out feeling better than when we arrived. Sadly, that was not the case for Elene.
If someone had taken the initiative to put all the facts together; ten days since the fall, ER visit twice in three days, excruciating pain, shortness of breath, the addition of neck pain, etc., Elene would be alive today. Further testing would have shown the beginning stages of pneumonia and staph infection, and God knows what else.
It became the perfect storm for a medical error; a busy, understaffed ER, resulting in conditions that made it more likely for human beings to make mistakes.
As a Human Performance expert, I know that studies show that 84 to 94 percent of all mistakes on the job (all professions) are set up by process, programmatic, or organizational issues. What that means is something, or things have set up the individual(s) involved to make that mistake.
I observed the following human error traps that day: time pressure, a distracting work environment, multi-tasking, and mentally stressed employees, to name a few. All that contributed to the fatal decision to discharge Elene without further testing.
All the pain she was experiencing became cover for what was going on internally. It should have been warning signs to the ER staff.
Studies have shown that traffic through emergency rooms in the United States has been on the rise. Americans visit the emergency room more than 140 million times a year. That's 43 visits for every 100 Americans.
Visits to the emergency room are more frequent than visits to primary care physicians. With this high volume of patients seeking treatment in the emergency room, hospitals must ensure they are adequately staffed to meet the demand. When an emergency room doesn't have enough staff, patients run the risk of being injured.
When emergency rooms are understaffed, this puts pressure on doctors and other medical professionals to turn over beds. This means that doctors do everything they can to get patients out of the emergency room.
In such a high-pressure environment, patients with severe conditions may be overlooked and don't receive the care they need (as I said above, it was ther perfect storm).
Elene fell victim to this organizational flaw during her second emergency room visit on 12-17-2012. A weakness in a system that ignored the obvious warning signs and contributed to the decision not to admit her for further testing. This flaw cost Elene her life.
On the morning of 12-18-2012, things began to accumulate to the point where Elene was totally incapacitated by the pain. At approximately 10:00AM, she told me that she couldn’t breathe and was in a lot of pain. She was so bad I had to call an ambulance to transfer her to the previous emergency room (after calling her primary care physician, who directed me to do so).
While at the hospital, she continued to have trouble breathing and experienced an elevated heart rate (159). She was immediately placed on oxygen, and throughout the day, several doctors came into the examination room, trying to figure out what was wrong with her.
X-rays were taken hours after we arrived, and blood was finally drawn at approximately 3:00 PM. Her hands were so cold the technician had a hard time drawing blood, and had to utilize heating pads to warm up her arm. Her organs were shutting down.
Communication with the ER doctor was beyond terrible. The one thing I remember about her was her lack of professionalism, and how busy and stressed she appeared to be. Asking her questions seemed to irritate her. The ER nurse who cared for Elene looked visibly frustrated and troubled by the entire atmosphere.
Elene was finally transported from the emergency room to the ICU at approximately 5:00 PM (seven hours after she arrived). I'll never forget the look in the ER nurse's eyes as she squeezed my hand tightly and said: "Good luck to you." Looking back, it was peculiar that the hospital staff never advised us that she was in danger of losing her life.
Interestingly, while other family members and I waited in the ICU family waiting room, a priest came into the room and asked if he could pray with us, leading us to believe for the first time that something was severely wrong.
We immediately went to the ICU reception area and asked why the priest came to pray with us and was told that it was hospital policy to comfort family members while a loved one was in the ICU.
We were ensured that everything was okay, and that the doctor would be out to brief us on her condition. Soon after, we met with the ICU doctor who advised us that Elene was very sick and that she would have a long night ahead of her, but he was confident she would pull through.
At approximately 11:30 PM, I was advised that she passed away after her heart stopped beating.
Since that awful night, all we have asked for as a family was for the hospital (as an organization) to accept responsibility for their failures during Elene's care.
I will say, some of their employees certainly have. One of the ICU doctors who cared for Elene was so distraught over Elene's ER care that he called me on 12-19-12 to personally offer me his condolences. He also promised to call me back when he had more answers as to her cause of death. He even called me on New Year's Eve and left a message that he would call back after the new year. A true professional.
On 01-02-13, as promised, the doctor called me back and advised me that the autopsy would not be ready for over a month due to toxicology testing. However, he did report that Elene's cause of death was due to pneumonia and complications from a staph infection.
He was very emotional during the call admitting that he was upset that Elene died and that he had a daughter the same age as our daughter (Nikki). I advised him that I was aware he took over Elene's care late in the process in the ICU, but the big question I had was, "How did she arrive to you in the condition she was in, after going to the ER for three of her last four days." He responded, "I agree, and you need to get those answers."
On 01-07-13, I met with Elene's primary care physician (also my primary care physician) for a physical. At that time, she vented that she was distraught over Elene's poor care at the hospital. She told me that she had spoken to the ICU doctor I mentioned above, and both were very upset about the care Elene received. She informed me that she was on the malpractice board at the hospital and would advise the board of her disappointment and concerns with the care provided to Elene at the next board meeting. She also stated that she believed the care provided to Elene was "negligence" and that "they should never have allowed her to go home" the day before she died.
Author's note: As of the date of this writing, she stands firm on her opinion of the hospitals' negligence in this case. A thought she has continued to voice to me during every office visit I have had with her since Elene's death (as recently as last week).
I have also been told that the ICU doctor showed tremendous courage by complaining to the hospital's risk management office soon after Elene's death, about the care she received in the ER.
Since Elene's death, independent experts conducted a complete evaluation of Elene's medical history and all hospital records documenting her care at the hospital. The experts found that based on all documented facts, the hospital failed to conduct several standard tests on Elene that the situation dictated. Moreover, the medical experts stated (including Elene's primary care physician) that Elene should never have been allowed to go home on 12-17-2012. Sending her home allowed things to escalate in a way that caused her death.
As of this date, the hospital as an organization has failed to accept responsibility for Elene's death. As in most cases, they hired lawyers who have dragged things out for over eight years—delaying depositions and requesting court delays that have continued to postpone our family's healing, while filling their own coffers with billable hours to the hospital.
As a human performance expert, that's eight years of a law firm billing a client (the hospital) by the hour. Think about that for a minute - money that could have been used for employee safety training. All the hospital had to do was accept responsibility promptly (as Elene's doctor said they would) to allow for closure, and more importantly, to implement a ‘lessons learned’ process to allow the hospital to move forward by providing a healthier work environment.
What saddens me most, is that eight years of the same hospital failures have been allowed to continue without being addressed. How many other lives have been lost since then?
Sadly, when they finally accept responsibility for this, they will have lost the window of opportunity for "real-time" organizational improvement.
This particular hospital is not alone in how it has handled this matter; it is an industry-wide mindset that takes hold for whatever reason. A philosophy where human errors are not discussed openly due to the fear of lost jobs and costly lawsuits. Learning opportunities are continually missed.
Even when someone does something nice and tries to change the culture, it is ignored.
When Covid-19 hit last year, and all the hospitals were overwhelmed with Covid-19 patients, I became very concerned that the potential for human error would increase in each hospital due to the same Human Error Traps that cost Elene her life.
I wanted to do something to help.
So, I wrote a blog entitled Will Covid-19 Influence Safer Workplaces? The intent was to remind hospital employees that the conditions they were working in would make it more likely for them to make a mistake, and to be aware of it.
At my own expense, I mailed 500 hard copies of the Error Elimination Tools Handbook mentioned in the above blog to Safety Directors at various hospitals in the US (including the one responsible for Elene's death), with a letter similar to the content offered in the blog. I had hoped that each director would pass out the FREE handbooks to the overworked employees as a reminder to pay attention to the human error TRAPS.
I did not do this for marketing purposes or to get work as a facilitator; I did this for Elene.
Sadly, not one person reached out to me and said thank you. It broke my heart and led me to the write this blog.
Rest in peace our special angel.
Bob Catinazzo, PPM
Practicing Perfection Institute
Executive Vice-President – Client Services
Bob Catinazzo is a decorated Senior Supervisory Agent for the DEA (retired), and is Director- Law Enforcement Services for the Practicing Perfection Institute. He has taught law enforcement professionals around the world, providing strategic and tactical insights in leadership and human performance.