Practice of Medicine

Claims Lesson

Meningitis - Communication Issues Result in a Delay in Diagnosis/Delay in Treatment

November 26, 2013

The Case

The patient, a 14-year-old athletic teenager, was taken by her parents to an urgent care center with complaints of ear pain and ear discharge. The nurse practitioner diagnosed her with otitis media and prescribed Vicodin and Floxin. A week later the patient's symptoms were worse and she was unable to walk. Her parents took her to their family practice (FP) physician.

The FP diagnosed sepsis, otitis media and dehydration, and sent the patient to the hospital for a lumbar puncture (LP) to rule out meningitis. The hospital nurses noted that the patient could not move her neck nor stand up; her pain was 10 on a scale of 1-10. The lumbar puncture revealed a cloudy fluid, and the radiologist sent it to the lab for analysis. However, he did not notify the FP of the results nor recommend further testing such as an MRI or CT scan of the head. In the meantime, the FP called the hospital and ordered a meningitis screen and meningitis precautions. He had no idea that the LP had been performed.

The FP left the office without reporting any of this information to his on-call partner, nor did he call the hospital for the LP results. The hospital called the FP's answering service to report an abnormal cerebrospinal WBC. After a second call, the on-call FP called and requested an infectious disease (ID) consult with the only ID physician in town. Neither the on-call FP nor the ID physician came in to examine the patient; the ID physician ordered a CT of the head for the following morning, two blood cultures, and Vancomycin. He did not ask, and was not told of, the patient's suspected meningitis or the LP results.

The following day, the ID physician arrived in the late morning and noted that the patient had become deaf and blind through the night as an "unfortunate result of meningitis." She was transferred to the ICU.

The patient continues to be seen for ongoing complications, including paraplegia, right ear deafness, vision problems, pain, mental impairment and motor deficits. She remains wheelchair bound, wears adult diapers and needs assistance to accomplish most tasks of daily living. The experts say she most likely will not be able to earn a high school degree or a GED, and will never be gainfully employed.

Allegation

Delay in diagnosis and delay in treatment, resulting in paraplegia/other permanent neurological & cognitive deficits.

Disposition

The case settled for a very large amount on behalf of both the hospital and our insured physicians.

Risk Management Commentary

None of the four physicians involved, including the radiologist, had direct conversations with one another. None of the treating physicians came in to see the patient in the hospital, except the ID physician who visited late in the process. The patient essentially was admitted to the hospital without treatment orders; the hospital nurses stood by over three shifts without communicating clearly with the on-call and ID physicians, without requesting orders, without performing any nursing care duties such as neurological checks, and so the patient suffered from the extreme outcome of the disease.

After reviewing this case, we listed some questions providers should ask themselves:

  • What are your on-call policies and procedures?
  • Do you have a system in place to report all critical information to your on-call partners or other providers?
  • What is your process for tracking and responding to critical lab/diagnostic test values?
  • How do you manage the "hand-off" of patients when several physicians are involved in each patient's care?

Disclaimer

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