Cases & Commentaries

Delay in Initiating Antibiotics Results in Fatal Error

Spotlight Case
Commentary By Lisa M. Bellini, MD

Case Objectives

  • Understand the importance of ongoing
    patient re-evaluation to confirm initial clinical impression.
  • Define the attending role with respect
    to "remote supervision."
  • Outline the role of the program director
    in processing medical errors.
  • List the different forums for processing
    medical errors.

Case & Commentary

A 21-year-old woman with a history of systemic
lupus erythematosus (SLE), on long-term prednisone, presented to
the emergency department (ED) with a few hours of fever, chills,
myalgias, and vomiting. On arrival to the ED, she was hypotensive,
but responded to IV fluid resuscitation. Laboratory evaluation
revealed an elevated white count. The medical housestaff evaluated
her, contacted the admitting attending by phone, and admitted the
patient to a medical ward with a presumptive diagnosis of viral
syndrome versus food poisoning. She continued to require fluid
resuscitation for blood pressure support. No antibiotics were
given.

In the morning, 10 hours after admission, her
condition began to deteriorate. She developed shock refractory to
fluid resuscitation, and a subtle petechial rash (Figure) was
noted. At that time, she was examined by the attending physician.
Suspecting meningococcemia, the attending started antibiotic
therapy and transferred the patient to the intensive care unit
(ICU). Despite initiation of antibiotics and full supportive
treatment, the patient had a cardiac arrest and died.

The error in this case reflects poor clinical
judgment and a fund of knowledge deficit. The first premise in
clinical care is to consider and treat the most life-threatening
conditions, while waiting for patients' illnesses to declare
themselves. Given her chronic prednisone use, this patient should
have been recognized as an unstable, immunosuppressed patient. The
differential diagnosis of hypotension in a patient on chronic
prednisone must include early sepsis and adrenal insufficiency.
Neither of these life-threatening conditions was apparently
considered. Concerns about early sepsis should have resulted in the
ordering of empiric broad-spectrum antibiotics and admission to an
intermediate care unit. Consideration of adrenal insufficiency
should have prompted the administration of intravenous
hydrocortisone. In this instance, the hypotension was ascribed to
volume depletion on the basis of a few hours of vomiting, an
unlikely explanation. Additionally, the patient continued to
require fluids for blood pressure support; the admitting team
should have re-evaluated her for this ongoing hypotension.
Continual patient re-evaluation is a critical skill, both to follow
the progression of underlying illness and to ensure that the team
is working with the correct diagnosis.

In this case, the attending physician was
contacted by phone, although the nature of that contact is not
specified. I refer to this type of supervision as "remote
supervision." It applies anytime an attending is not physically
present in a patient care unit to personally evaluate and manage
patients. Remote supervision of residents is the most common
mechanism of housestaff supervision, whether overnight or during
the day. Oftentimes, faculty physicians are admitting patients
(remotely) while simultaneously seeing outpatients. They make
rounds late at night or early in the morning and thus rely on
remote communication of clinical changes. Additionally, most
institutions do not require overnight faculty presence. If
institutions are going to care for patients this way, then
standards must be set for quality of care. New admissions must be
presented in their entirety to the attending. If the attending has
any concerns regarding the clinical skills or decision making of
the team, then he or she must evaluate the patient personally. This
standard should be applied regardless of time of day.

Changes in inpatient medicine over the past 10
years challenge the concept of remote supervision. Given the
managed care revolution, the need to manage patients effectively
has become a fiscal imperative. Cost containment and demands for
improved quality of care have led to the birth of a new specialist
in medicine: the hospitalist. Defined as individuals who practice
at least 25% time in the inpatient setting (1),
hospitalists hold the advantage of having the inpatient ward as
their practice venue. They are present in the hospital more often
(around the clock in some institutions), enabling the timely
evaluation of patients. Supervision is no longer remote. Although
there are no data to confirm that fewer errors occur on hospitalist
services, two studies at teaching hospitals showed that
hospitalists led to reduced lengths of stay, cost of care, and
mortality.(2,3) In an
analogous way, the on-site presence of intensivists (who are, in
essence, "ICU hospitalists") appears to improve outcomes (4), and has
been promoted by the Leapfrog group as one of its quality
standards.(5)

Although the data are limited, it makes intuitive
sense that the more timely involvement of attending physicians such
as hospitalists and intensivists would lead to less expensive and
better quality care. Nevertheless, a recent study on the presence
of in-house attending trauma surgeons showed no impact on mortality
or length of stay.(6) Studying the
impact of different organizational models of care is notoriously
difficult, and institutions will need to decide on staffing and
supervision models based on imperfect data.

The rapid growth of the hospitalist
model—both within and outside academic hospitals—seems
to indicate that leaders are convinced of its benefits.(7) The
introduction of hospitalists into academic medical centers is
likely influencing graduate medical education.(8)
One great challenge is to balance resident autonomy with the
appropriate level of supervision when hospitalists are integrated
into training programs. At least one study supports that their
presence does not compromise resident autonomy.(9)

The duty-hour regulations imposed by the ACGME in
July 2003 are also likely to impact and change the level of
attending involvement. These regulations require that, when
averaged over 4 weeks, housestaff work no more than 80 hours per
week and have 1 day in 7 off. They also require that every duty
period be separated by 10 hours and that no shift exceed 24
continuous hours with an additional 6 hours for education and
transfer of care.(10) To meet
these requirements, many programs have implemented or expanded
night-float programs.(11,12) The
number of handoffs between providers has certainly increased. This
discontinuity of care by housestaff places more reliance on the
attending physicians for the details of patient care. It is likely
that duty-hour reform will improve resident fatigue; however, it
may compromise patient safety. New systems will need to be adopted
to improve continuity. One such mechanism would be to have
continuous presence of hospitalists throughout the day and
night.

At least one study demonstrates that medical
errors among internal medicine residents are not uncommon. One
hundred fourteen internal medicine residents completed an anonymous
questionnaire describing their most significant mistake and their
response to it.(13) Mistakes
included errors in diagnosis (33%), prescribing (29%), evaluation
(21%), communication (5%), and procedural complications (11%).
Serious adverse outcomes occurred in 90% of the cases, including
death in 31% of cases. Most importantly in this study, only 54% of
house officers discussed the mistake with their attending
physicians, and only 24% told the patients or families. Those who
accepted responsibility for the mistake and discussed it were more
likely to report constructive changes in practice.(13)

Given that errors are not uncommon among
residents and accountability is less than adequate, program
directors and those responsible for medical education play a
critical role in patient safety. The overall role of the program
director is to help residents turn into independent practicing
physicians. Errors related to fund of knowledge deficits,
inadequate clinical skills, poor clinical judgment, and problem
solving must be addressed from the perspective of the individual,
the program, and the health care system. Errors never occur in a
vacuum: usually, system-based issues are contributing factors.

Program directors have three roles when it comes
to dealing with medical errors. The first relates to the providers:
the responsible faculty must discuss the error with the house
officers involved. Oftentimes, the program director can facilitate
this. Many housestaff worry when their program director is notified
of their mistakes, concerned that such information will harm their
fellowship or job prospects, or that they'll be sued or suffer
personal embarrassment. Regardless, the program director is the
only individual who can determine whether an error is an isolated
circumstance or represents a problematic pattern of performance. If
such a pattern is present, then it needs to be carefully examined.
The pattern may reflect basic fund of knowledge and clinical skills
deficits that are easily remediable. It may also reflect underlying
depression, attention deficit disorder, substance abuse, etc. All
of these issues must be addressed for residents to successfully
negotiate training.

The second role of the program director is in
defining the educational curriculum. If the error is felt to be
common within the program, then the program director should develop
an educational initiative designed to prevent similar occurrences,
such as a resident report, clinicopathological conference (CPC), or
Morbidity and Mortality (M&M) conference devoted to discussing
the case. The third role of the program director is to serve as a
liaison between the program and the health care system. If
significant systems issues are identified, then that information
needs to be communicated to the appropriate individuals in the
hospital administration. Too often, there is a disconnect between
residency issues and the institutional quality apparatus.
Residents, by operating at the sharp end of care, are
often the ones best positioned to identify major systems flaws that
require action.

The barriers mentioned above are very real and
impact our ability to learn from our mistakes. At our institution,
we have adopted several venues for error reporting that have helped
the program directors carry out all three roles. We now have
monthly patient safety discussions at residents' report. In these
sessions, we discuss cases where errors or potential errors were
thought to occur due to systems-related issues in the process of
care. Importantly, the vice president for hospital quality and
patient safety moderates these sessions. The format has enabled the
identification of many systems issues that have subsequently been
improved. While initially skeptical, the housestaff have embraced
this format as a constructive way to have a voice in the larger
process of care.

In addition to reporting within these and other
conferences (eg, M&M conferences), we have also implemented an
anonymous web-based reporting system called Penn Occurrences
Reporting and Tracking System (PORTS). This system allows any
provider to submit an online report of any situation that created a
near miss for an adverse event or actually caused an adverse event.
This information is collected and collated centrally by the
institution-based Clinical Effectiveness and Quality Committee.
Their role is to identify not only individual events but also look
for patterns of events that can lead to systems-based improvements.
Residents in our program have embraced this anonymous reporting
tool as a way to improve the system of care at our hospital.

If error reporting is done in a non-biased,
non-confrontational format with an opportunity for learning, it can
lead to substantial improvements in both education and patient
care. As physicians, we have a responsibility to ourselves and our
patients to develop systems to minimize errors. As educators, we
have an obligation to help trainees understand the importance of
their roles as both providers of care for individual patients and
as leaders in improving the systems of care in which they work.
Recognizing the complex factors that contribute to these errors is
necessary to prevent future occurrences.

Lisa M. Bellini,
MD
Associate Professor of Medicine
Vice Chair for Education and Inpatient Services
Department of Medicine
University of Pennsylvania Medical Center

Faculty Disclosure: Dr. Bellini has
declared that neither she, nor any immediate member of her family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, her commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.

References

1. Wachter RM. An introduction to the hospitalist
model. Ann Intern Med. 1999;130:338-42.[ go to PubMed ]

2. Auerbach AD, Wachter RM, Katz P, Showstack J,
Baron RB, Goldman L . Implementation of a voluntary hospitalist
service at a community teaching hospital: improved clinical
efficiency and patient outcomes. Ann Intern Med.
2002;137:859-65.[ go to PubMed ]

3. Meltzer D, Manning WG, Morrison J, et al.
Effects of physician experience on costs and outcomes on an
academic general medicine service: results of a trial of
hospitalists. Ann Intern Med. 2002;137:866-74.[ go to PubMed ]

4. Pronovost PJ, Angus DC, Dorman T, Robinson KA,
Dremsizov TT, Young TL. Physician staffing patterns and clinical
outcomes in critically ill patients: a systematic review. JAMA.
2002;288:2151-62.[ go to PubMed ]

5. Fact sheet. The Leapfrog Group. October 2003.
Available at:
[ go to related site ]. Accesed January 13, 2004.

6. Arbabi S, Jurkovich GJ, Rivara FP, et al.
Patient outcomes in academic medical centers: influence of
fellowship programs and in house on call attending surgeon. Arch
Surg. 2003;138:47-51.[ go to PubMed ]

7. Wachter RM, Goldman L. The hospitalist
movement 5 years later. JAMA. 2002;287:487-94.[ go to PubMed ]

8. Shea JA, Wasfi YS, Kovath KJ, Asch DA, Bellini
LM. The presence of hospitalist in medical education. Acad Med.
2000;75:S34-6.[ go to PubMed ]

9. Chung P, Morrison J, Jin L, Levinson W,
Humphrey H, Meltzer D. Resident satisfaction on an academic
hospitalist service: time to teach. Am J Med. 2002;112:597-601.[ go to PubMed ]

10. Resident duty hours language: final
requirements. Accreditation Council of Graduate Medical Education
Web site. February 13, 2003. Available at:
[ go to related site ]. Accessed January 22, 2004.

11. Morelock JA, Stern DT; Association of
Professors of Medicine. Shifting patients: how residency programs
respond to residency review committee requirements. Am J Med.
2003;115:163-9.[ go to PubMed ]

12. Resident work hours benchmarking project
summary. University Health System Consortium Web site. June 2003.
Available at:
[ go to related site ]. Accessed February 9,
2004.

13. Wu AW, Folkman S, McPhee SJ, Lo B. Do house
officers learn from their mistakes? JAMA. 1991;265:2089-94.[ go to PubMed ]

Figure

Figure. Petechial Rash