You are Dr. Magdalena Ríos-Echaurren, 49, Chief Medical Officer of Clínica San Pelayo, a 540-bed tertiary teaching hospital in Santiago de Chile. Six weeks ago, a 64-year-old patient died of an unrecognised post-operative haemorrhage that three nurses had flagged in the EHR but never escalated. The Board wants your proposal by Friday.
The situation
San Pelayo is a high-reputation, high-volume hospital — 28,000 admissions/year, 92 ICU beds, three of the country's strongest surgical programs (cardio, neuro, hepato-biliary). On most quality dashboards the firm sits in the top decile of Chilean clinics. On this dashboard — the one that counts sentinel events, near-misses, and the gap between what nurses know and what attending physicians act on — the picture is more uncomfortable.
Internal incident review of the sentinel death surfaced a pattern: three nurses in three separate 12-hour shifts saw deteriorating vitals, recorded them in the EHR, called the resident, and were told "she'll be fine, focus on bed 14." None escalated to the consultant. None used the existing "rapid response team" pager. Two of them said, in the post-event interview, the same sentence: "In this hospital, you don't stop the surgeon."