TWO DAYS earlier, the junior assistant (first-year) resident had telephoned and requested that the family come to the hospital for a meeting at 1 PM. On the appointed day, the patient's mother, father, older brother, and younger sister traveled 3 hours from their home in Upstate New York. When they arrived, however, the resident was nowhere to be found. He had signed out when his day off began at noon and could not be located despite vigorous efforts. After waiting in vain for the next 2 hours, hoping that the resident might appear, the family departed for their return home.
The resident had left the hospital without letting anyone know about the family's impending arrival, why he had asked them to come, or what to do with them. He also had left no word about how he might be reached before his scheduled return to work the next morning, when
Feinstein AR. System, Supervision, Standards, and the 'Epidemic' of Negligent Medical Errors. Arch Intern Med. 1997;157(12):1285–1289. doi:10.1001/archinte.1997.00440330015002
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