Search Cases

A three-year-old patient had a congenital duodenal stenosis with malrotation of the GI tract and short gut syndrome.  She had a central line and had a history of infections of her central line.

On 4/22/2003 the patient was taken to the emergency department at 11:30 p.m. for a suspected infection of her central line.  The ED physician evaluated the patient.  The patient had a temperature of 102.2, pulse was 199, respirations were 28, her O2 saturation was 96%, and she was lethargic.  The ED physician was unable to view her entire history as the hospital was experiencing computer problems that night.  The patient’s physician was on-call, but the ED physician did not attempt to reach him for information about the patient.

The ED physician took blood for cultures and treated the suspected central line infection with an infusion of Amphotericin B and a Tylenol suppository.  He did not prescribe broad-spectrum antibiotics.  Although he suggested that the patient be admitted to the hospital, he acquiesced when the patient’s parents said they would prefer to take her home.  The patient was discharged on 4/23/2003 at 3:12 a.m.

At approximately 5:33 a.m., the patient’s parents found her breathing very slowly and without air exchange.  She was taken by ambulance to another emergency department.  Attempts at resuscitation failed, and she was pronounced dead at 6:17 a.m.  The blood culture ordered by the ED physician came back positive for Escherichia Coli.

The Board ordered that the ED physician pay the costs of the proceeding, be reprimanded, and complete 8 hours of continuing education in identifying and treating central line infections.

State: Wisconsin

Date: July 2005

Specialty: Emergency Medicine, Pediatrics

Symptom: N/A

Diagnosis: Sepsis, Gastrointestinal Disease

Medical Error: Improper medication management, Diagnostic error, Failure of communication with other providers, Physician concern overridden

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF