The errors in this case would be considered preventable, “acts of omission” reflecting poor clinical judgment, fund of knowledge deficit and the pitfalls of “remote supervision” by attending physicians. According to the NCC MERP Index for error coding, such errors would fall under Category I: errors that contribute to or result in patient’s death. While easy to attribute these errors to the individuals involved, they are most likely a result of system challenges to the hospital and its residency program.
Although the source of the symptoms was unknown upon admission to the ED, hypotension when combined with elevated white cell count, fever, myalgia and vomiting, should have indicated a possible bacterial infection. Further, medical staff should have foreseen that such symptoms, when presented in a young woman with a compromised immune system and long term prednisone use, might indicate early sepsis and adrenal insufficiency (the most life-threatening conditions) and prompted the immediate administration of empiric broad-spectrum antibiotics, intravenous hydrocortisone, and admission to the ICU.
Failing to connect the dots in the case, the admitting team was unable to take the correct steps to stabilize the patient. No re-evaluations were conducted even as the patient continued to require fluids to support her blood pressure causing the team to continue to treat the patient incorrectly. In turn, the team did not adequately present the case “remotely” to the attending physician over the phone. It was only after 10 hours that the patient was seen for the first time by the attending physician at which point it was too late.
Lack of supervision by a faculty physician left the residents on their own to correctly, or in this case incorrectly, diagnose and treat the patient. Without standards of care in place, the case was not presented in its entirety to the attending, who was also unable to correctly diagnose or treat the patient.
The system failed in four...