On 6/8/2012, a 16-year-old female presented with complaints of tactile fever for the previous four days, coughing, and one incident of post-tussive emesis.
A pediatrician performed an examination and documented that the patient’s temperature was 98.3, her heart rate was 98, and her respiratory rate was 22. The patient’s weight was also documented to be 209 pounds.
The pediatrician assessed the patient was suffering from an upper respiratory infection (URI) and recommended that she continue over-the-counter medication to manage her symptoms.
On 6/9/2012, the patient again presented to the pediatrician. She presented with the same complaints of fever and coughing, but additionally complained of a sore throat.
The pediatrician performed an examination and documented that the patient’s heart rate was 106 and her respiratory rate was 32. She was also running a temperature of 100.8.
The pediatrician assessed that the patient had a URI and pharyngitis. The pediatrician provided the patient with respiratory instruction and advised that she should return in two days if her temperature persisted.
Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not order a STAT chest x-ray for the patient. Despite the increase in the patient’s heart rate and respiratory rate from the 6/8/2012 and 6/9/2012 visit, the pediatrician did not check the patient’s oxygen saturation.
On 6/10/2012, the patient expired in her home. The medical examiner documented the patient’s cause of death as pneumonia with sepsis due to haemophilus influenzae.
The Medical Board of Florida judged the obstetrician’s conduct to be below the minimal standard of competence given that he failed to order a STAT chest x-ray and check the patient’s oxygen saturation.
The Medical Board of Florida issued a letter of concern against the pediatrician’s license. The Medical Board of Florida ordered that the pediatrician pay a fine of $5,000 against his license and pay reimbursement cost at a minimum of $1,408.03 and a maximum of $3,408.03. The Medical Board of Florida ordered that the pediatrician complete five hours of continuing medical education in pediatric medicine and complete three hours of continuing medical education in diagnosis and treatment of pneumonia.
Date: August 2017
Medical Error: Failure to order appropriate diagnostic test
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
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