Lack of communication among emergency room staff, poor configuration of information on the patient's electronic health record and diminished focus on patient safety were three of the main deficiencies of Texas Health Presbyterian Hospital in Dallas where a man infected with the Ebola virus was misdiagnosed last year and died, according to an independent report released by the hospital Friday.

"The lack of complete history taking, particularly travel history assessment, documentation and sharing, the ineffective communications among the clinical team and a seeming overreliance on the EHR [electronic health record] rather than focusing on the complete care of the patient, leads the Expert Panel to recommend a broad review of the quality of care. . . . IT [Information Technology] . . . and the culture of the THD [Texas Health Presbyterian Dallas] Emergency Department," the report says.

The hospital asked the five health-care officials on the expert panel to review the events surrounding Thomas Eric Duncan, the Liberian emigre who arrived at the hospital Sept. 25, 2014, and who, hours later, even after his fever reached 103 degrees, was sent home with a diagnosis of sinusitis.

Duncan died two weeks later, and two nurses who treated him, Nina Pham and Amber Vinson, were eventually diagnosed with ebola too, but survived.

The report criticized the staff in the emergency department for not verbally communicating information about Duncan's recent travel to Liberia, where ebola was rampant, and which was entered into the electronic health record.  The 15-page report also said the hospital's electronic health record's failure to have automatic alerts related to questions on travel history contributed to Duncan's misdiagnosis on his first visit.

The five health-care experts, all from outside Texas,  convened in February at the behest of Texas Health Resources, the corporate parent of Texas Health Presbyterian Hospital, and with the authorization and support of the hospital's board of trustees. Their job, according to the report, was to review the facts of the events "surrounding the care and ultimate death of Mr. Thomas Eric Duncan from [ebola] and the transmission of the virus to two nurses," who both made full recoveries, and to make recommendations.

Texas Health Resources also issued a press release about the expert panel's findings.

"We welcome this panel's report and believe that it will lead to better diagnoses of diseases in our emergency rooms, better care for our patients overall and better coordination with local, state and federal officials in the event another rare event like this unfolds," said Barclay Berden, CEO of Texas Health Resources, in his public statement. "We're hopeful that these findings will also help hospitals and health systems across the country be better prepared for future novel events."

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