Statistically valid inference from a single patient case study is, of course, not possible. However, as a practicing health care executive with some 30 years of experience, I have found that motivation for administrative action is typically not predicated on formal data collection and analysis.
It fortunately appears that the clinical outcome for the patient was favorable. Therefore, let me turn my attention to standard practices in the 6 university hospitals with which I have been associated in my career. As is the case in any customer-focused enterprise, all hospitals with which I am familiar will routinely seek feedback with respect to the satisfaction of patients served.
As a senior executive, I have always attempted to set the bar for patient experience in the hospital rather high. Subject to the inevitable stress associated with compromised physical and/or mental functioning, I have generally found that patients departing the hospital will make ample allowances for minor inconveniences. National survey instruments routinely used by hospitals to gauge patient experiences (Gallup, Press-Ganey) report overwhelming (generally 87% plus) satisfaction with their inpatient care. This includes clinical aspects and hotel aspects; however, adequacy of food services and parking are typical opportunities for improvement.
In any event, a communication like this one would be a call to action in the administrative suite. The number of errors, omissions, potential errors, and otherwise discouraging number of process issues in this admission are cause for administrative attention and intervention. I would call on a patient representative or junior manager to trace the patient experience from start to finish and, insofar as possible, to validate the chain of events in a dispassionate manner.
A first question for any competent health care executive is the degree to which the incidents described are generalizable and demanding of system and procedure overhaul versus a random "perfect storm" in which much of what could go wrong did. Pattern analysis of patient comments with similar diagnostic and treatment circumstances will answer this to some degree, and formal data collection could also be warranted. For the moment, assuming the authors' material degrees of freedom with respect to hospital selection, I shall suppose that the institution involved has a first-class reputation and is a leading teaching hospital. If this is accurate, I would send the patient and his spouse a thorough report of the management's findings, conclusions, and recommendations, along with an expression of gratitude for bringing these shortcomings forward in order that improved circumstances can be made available to other patients.
Assuming that the patient's experience reflects generalizable process control problems, I would preliminarily conclude that this hospital is in need of basic administrative remedies, without which its public reputation will ultimately be affected adversely. At worst, there is an adverse patient event waiting to happen.