Although the Yale patient recovered, his illness was never deciphered by the large team of physicians. Study authors Stavert and Lott say medical school education and health-care protocols need to be improved.
They say some research suggests that bystanders are more likely to act if they are friends with one another. The hospitals should encourage more collegiality across the disciplines.
"People can have a greater level of comfort and sense of ownership to increase their confidence to act or share an idea," Stavert said.
New federal health safety programs like TEAMSTEPPS (Team Strategies and Tools to enhance Performance and Patient Safety) are also critical to improving communication between doctors, they said.
"I think we are doing such a better job of taking care of disease in general, but the level of acuity of patients admitted to the hospital is so much higher than it was 40 or 50 years ago," Lott said.
"The problem becomes it's more difficult to coordinate care and also to keep your eye on the ball. We are not doing as good as we could."