The Board was notified of a professional liability payment made on 6/5/15.

A 31-year-old male with end-stage renal disease presented to the emergency department with cough, fever, and acute pain.  The initial diagnosis was sepsis.  He was given cefazolin and gentamicin.  The patient’s allergy history was noted to include penicillin and vancomycin.

The patient subsequently underwent two transfers of care.  During these transfers, it was indicated by various physicians that the patient would require intravenous vancomycin to treat sepsis.  Given the patient’s ambiguous allergy history, the evening hospitalist made the decision to defer to a nephrologist the decision regarding the treatment of the patient with vancomycin as the nephrologist had treated the patient in the past.  As the patient’s nephrologist, he was aware that the patient had received vancomycin in the past both intravenously and intraperitoneally.  The patient had previously developed tachycardia and dyspnea after receiving vancomycin.  The nephrologist had concluded that the patient’s reaction to the most recent exposure to vancomycin was not a true allergic reaction, but rather “red man syndrome” and that the patient now required vancomycin to successfully treat the sepsis.  Within minutes of the start of the vancomycin infusion, the patient developed tachycardia, dyspnea, and ultimately cardiac arrest from which he could not be revived.

The Board expressed concern that the nephrologist’s care of the patient fell below the standard of care.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina

Date: February 2017

Specialty: Nephrology

Symptom: Fever, Cough

Diagnosis: Sepsis

Medical Error: Improper medication management, Underestimation of likelihood or severity

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF