Medical Malpractice Insights: Delayed Care, Poor Handoff, Multiple Errors

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Delayed care, poor handoff, multiple errors 

A 2-year-old with meningitis left with major disability. A classic example of how “assume” can make an “ass” of “u” and “me”

Facts: A 2-year-old male presents to the ED shortly after noon with fever, pain, and vomiting. The triage nurse describes him as lethargic, eyes closed, neck stiff, and no response to having his rectal temp (104F) taken. A history of ear infection treated with antibiotics 1 week prior is documented. He is assigned a triage level of 2 due to suspected meningitis. He is placed in an exam room, but the emergency physician is not alerted. Over the next 2 hours the emergency physician on duty sees 3 lower acuity patients before the end of his shift. At 1400 the oncoming emergency physician sees the patient and recognizes the child’s likely problem immediately. He calls a pediatrician and has no further contact with the patient. The pediatrician sees the child at 1430 and orders a CT scan which is reported at 1630 as showing only mild ventriculomegaly. The pediatrician sees the child again at 1855, does an LP, arranges admission, and orders ceftriaxone and vancomycin. However, not being familiar with ED protocols, he writes the order on the inpatient “physician orders” page rather than on the ED chart. The orders are thus not seen by the ED team and the ceftriaxone not administered until 2100 in the ED. The vancomycin is given even later (2230) after the child arrives in the pediatric ICU. By this time, 10 1/2 hours after arrival in the ED, the child is unresponsive. He recovers but is left with permanent cognitive disability beyond that of a 2-year-old. The family claims delay in diagnosis and treatment, and a lawsuit is filed.

Plaintiff: My child had obvious signs and symptoms of meningitis. The triage nurse documented classic findings but failed to alert the doctor to the patient’s condition, so my son waited 1 1/2 hours to see the doctor. The first emergency physician should have seen my son immediately, done the LP right away himself, and started antibiotics. Instead, he left my son to the oncoming emergency physician who punted my son off to a pediatrician who was busy with other patients. Both the second emergency physician and the pediatrician should have assured that my son got immediate antibiotics and paid attention to his progress. The hospital should have better policies regarding nurses alerting physicians, the role of consultants, handoffs, who’s in charge of patients in the ED, and orders written there. If not for your negligent care, my son would have recovered from the meningitis.

Defense:

• All: You waited too long to bring your child to the ER. Another few hours would not have made a difference.
• Triage Nurse: I documented all of the child’s symptoms and assumed that my teammates would see the child right away and get the doc involved immediately.
• ED Doc 1: No one told me there was a sick child for me to see or I would have seen him right away.
• ED Doc 2: Someone should have seen this patient before me. I saw your son as soon as I came on shift. I wanted a pediatrician’s input on the proper antibiotic since your son had just been on one for his ear infection a week ago. I assumed he would take it from there.
• Pediatrician: When I wrote the orders, I assumed the ED nurses would act on them. No one ever told me I had to write the orders on the ED chart. I also assumed that the ED doc would let me know if there were any problems.
• ED Nurse: The pediatrician wrote the orders in the wrong place. We never carry out inpatient orders, even if the patient is still in the ED.

Result: Mediated pre-trial settlement for $10.9 million.

Takeaways:

• Nurses are liable for not informing physicians of high acuity patients.
• Treat the sickest patients first. Going off shift does not justify delaying the treatment of meningitis – or any Triage Level 2 patient.
• Antibiotics should be given first if a CT scan or LP would otherwise delay treatment of suspected meningitis.
• Until a patient physically departs the ED, the ED doc is responsible for that patient unless a clear written handoff has occurred. A bedside handoff is always best.
• If care has indeed been handed off to an inpatient physician, communication must be clear as to who is in charge, what orders are expected, when, from whom, who is to execute them and where.
• Informal practices that affect patient care (like not carrying out admission orders) are unacceptable. If they rise to the level of policy, the policy should be clearly communicated and understood by all affected.

References:

• Tunkel et al. Practice Guidelines for the Management of Bacterial Meningitis, Clinical Infectious Disease 2004; https://academic.oup.com/cid/article/39/9/1267/402080/Practice-Guidelines-for-the-Management-of
• Muller ML.Pediatric Bacterial Meningitis. Medscape eMedicine. Updated: Jan 16, 2019. https://emedicine.medscape.com/article/961497-overview
• Pilcher CA. Handoffs and Consults: Who’s in charge? Part I. Medical Malpractice Bulletin, May, 2013. http://pilchermd.com/2013/05/04/handoffs-and-consults-whos-in-charge-part-i/
• Pilcher CA. Handoffs and Consults: Who’s in charge? Part II. Medical Malpractice Bulletin, June, 2013.