Cases & Commentaries

To LP or Not LP

Commentary By Christopher P. Landrigan, MD, MPH

The Case

A 4-month-old male infant was seen in the office
setting of a large multisite practice. He presented with fever and
irritability without an obvious source. He was referred to the
local pediatric emergency department for further evaluation.
Parents were advised the reason for the referral was so that he
could get a "blood test" performed.

Because the clinic was busy, the provider was
unable to call the emergency department (ED) physician in a timely
manner. The parents presented to the ED and said they were there
for a "blood test" and were referred to a local lab for further
evaluation. At the lab, they were informed that the doctor had not
called in any lab test orders. The lab asked the patient´s
family to wait while the physician was called, but while waiting
the infant became more obtunded and toxic. At that point, the
parents decided to leave and go to another hospital ED for
evaluation. Meanwhile, the original physician called the first ED
for the lumbar puncture (LP) results. He was informed that the
patient had been sent to the lab and was not seen in the ED. At the
second ED, an LP was done after another physician evaluation, and
the child was diagnosed with meningitis. Despite the several-hour
delay, the child was treated with 10 days of medication and
recovered fully.

The Commentary

This case highlights an important problem in
pediatrics, the evaluation of the febrile infant, as well as two
problems common across medical disciplines: diagnostic delay and
failures of communication. Fortunately, no long-term sequelae
occurred as a consequence of the errors in care suffered by this
patient, but the outcome could have been tragic.

Management of the febrile infant without obvious
source has been a subject of intense study over the past decade.
The high incidence of severe, invasive bacterial illness among very
young febrile infants without identifiable source has led to the
development of well-substantiated practice guidelines regarding
their management. Current recommendations are that all febrile
children younger than 1 month of age should have samples of
cerebrospinal fluid (CSF), blood, and urine taken to rule out the
presence of bacterial infection (1) and
should be treated with parenteral antibiotics. For well-appearing
children who are slightly older (1 to 36 months of age), there is
considerably more debate about the optimal course of action
(2-4),
but the broad consensus is that an ill-appearing child should be
thoroughly evaluated and treated expectantly while awaiting
cultures. In this case involving a 4-month-old, unexplained
irritability with fever would merit a lumbar puncture and
intravenous (IV) antibiotic therapy, particularly if the
irritability were severe or prolonged.

The provider´s referral of this patient to
the local ED, and follow-up call to learn the results of the lumbar
puncture indicate that he was appropriately concerned about the
possibility of meningitis or other occult infection. The plan to
refer the patient was sound, but the provider made errors in
executing this plan, which facilitated a cascade of additional
downstream errors. Four distinct errors occurred in this case.
First, the provider failed to directly contact the ED and convey
his concerns. Second, there was an undefined breakdown in
communication between the provider and the patient’s family,
which led them to not completely understand the reason for their
visit to the ED. Ideally, the provider should have ensured the
patient’s family had more accurate information before sending
them out of the office. Third, in part because the ED did not
receive important information directly from the referring provider,
the ED failed to obtain an adequate history from the
patient’s family before sending him to the lab. Fourth, as a
consequence of the confusion generated by errors one through three,
there was an avoidable delay at the laboratory, during which time
the patient deteriorated and required a visit to a second ED.

It is easy to identify erroneous actions in this
scenario, but one should recognize that these errors did not occur
in a vacuum. The errors in execution made by the original provider
likely would not have occurred in less hectic working conditions.
The ED and laboratory could have been more proactive about
clarifying information, but had errors one and two not occurred,
they would almost certainly not have been in positions to make
errors of their own. In other words, both "active" errors (on the
part of individuals) and "latent" errors (deeper
problems in how the systems operated) conspired to cause a problem
for this patient: a delay in diagnosis. Indeed, most adverse events
suffered in medicine are the consequence of multiple small failures
such as these, each of which may be independently insufficient to
cause harm.(5)

As Leape points out, cognitive psychologists have
long known that errors in the completion of routine tasks are
particularly likely to happen when one is working under suboptimal
conditions.(6)
Sleep deprivation, distractions, emotional pre-occupations, or as
is cited in this case, overwork, all predispose us to error. In a
busy clinic, where overwork and distractions are the norm, such
errors will inevitably occur from time to time.

It is interesting to note that all four of the
errors in this scenario involved breakdowns in communication. The
first two errors involved the provider’s failure to
communicate with the ED and patient’s family respectively.
The combination of these failures left the family inappropriately
responsible for conveying crucial clinical information they did not
adequately understand. The third error was due to a failure of the
ED to adequately question the family’s reason for arrival at
the ED, which was made far more likely as a consequence of the
first two errors. The fourth error was a communication delay.

In a study of medication errors in an adult
hospital, investigators at Brigham and Women’s Hospital found
that cross-coverage of unfamiliar patients was associated with a
roughly 6-fold increase in the incidence of medication errors
(7),
suggesting that knowledge deficits and inadequate communication
about patients led to increased error rates. Interestingly, in a
second study, the same investigators found that this increased risk
of error virtually disappeared following the introduction of a
structured, computerized sign-out tool used by housestaff to
exchange critical patient care information.(8) In a study of strategies to prevent pediatric
medication errors, it was found that optimal communication could
have prevented 86% of all errors detected.(9) Communication problems are crucial sources of error
across medical systems. Hospitals and health care systems that
successfully improve communication will unquestionably reduce
errors not only in medication delivery, but in diagnosis and the
performance of complex procedures.

The end product of the series of latent errors,
errors in execution, and communication breakdowns in this case was
a delay in diagnosis and management of a very time-sensitive
illness, meningitis. In the Harvard Medical Practice Study,
diagnostic mishaps were the fourth most common type of error, and
the category of error most likely to be deemed negligent.(10)
While a delay in diagnosis of hours would be trivial for many
illnesses, it could be fatal in the case of a rapidly invasive
bacterial illness. Meningococcus in particular, one of the more
common causes of bacterial meningitis in children, can cause a
rapidly progressive illness that is more likely to be fatal if not
diagnosed and treated promptly.(11)

Take-Home
Points

Many of the issues discussed above are complex,
and will improve only as automated systems of communication
develop, as working conditions improve, and as the culture of
medicine gradually becomes more safety-conscious. There are,
however, a few simple steps that if followed routinely, would have
prevented this particular scenario from unfolding:

  • Health care providers should establish a
    system to provide patients with a written description of the reason
    for referral when sending them emergently to an ED.
  • Furthermore, providers should establish
    a system to ensure that a receiving provider in the ED is spoken
    with directly. In settings where providers cannot realistically
    accomplish this goal themselves 100% of the time, a system should
    be established that assures this step is completed (eg, designating
    a nurse to make direct contact with the ED in all such cases).
  • Designated ED staff (perhaps triage
    nurses) should confirm the reason for referral of all patients sent
    from another health care provider whenever it is unclear.

Christopher P.
Landrigan, MD, MPH
Research Director, Children´s Hospital Inpatient Pediatrics
Service
Associate Physician, Brigham and Women´s Division of Sleep
Medicine
Harvard Medical School
Boston, Mass

References

1. Baraff LJ, Bass JW, Fleisher GR, et al.
Practice guideline for the management of infants and children 0 to
36 months of age with fever without source. Agency for Health Care
Policy and Research. Ann Emerg Med. 1993;22:1198-210.[ go to PubMed ]

2. Kramer MS, Shapiro ED. Management of the young
febrile child: a commentary on recent practice guidelines.
Pediatrics. 1997;100:128-34.[ go to PubMed ]

3. Baraff LJ, Schriger DL, Bass JW, et al.
Management of the young febrile child. Commentary on Practice
Guidelines. Pediatrics. 1997;100:134-6.[ go to PubMed ]

4. King C. Evaluation and management of febrile
infants in the emergency department. Emerg Med Clin North Am.
2003;21:89-99.[ go to PubMed ]

5. Reason JT. Human error. New York: Cambridge
University Press; 1990.

6. Leape LL. Error in Medicine. JAMA.
1994;272:1851-7.[ go to PubMed ]

7. Petersen LA, Brennan TA, O´Neil AC, Cook
EF, Lee TH. Does housestaff discontinuity of care increase the risk
for preventable adverse events? Ann Intern Med.
1994;121:866-872.[ go to PubMed ]

8. Petersen LA, Orav EJ, Teich JM, O´Neil
AC. Using a computerized sign-out program to improve continuity of
inpatient care and prevent adverse events. Jt Comm J Qual Improv.
1998;24:77-87.[ go to PubMed ]

9. Fortescue EB, Kaushal R, Landrigan CP, et al.
Prioritizing strategies for preventing medication errors and
adverse drug events in pediatric inpatients. Pediatrics.
2003;111:722-9.[ go to PubMed ]

10. Leape LL, Brennan TA, Laird N, et al. The
nature of adverse events in hospitalized patients. Results of the
Harvard Medical Practice Study II. N Engl J Med.
1991;324:377-84.[ go to PubMed ]

11. Cartwright KA. Early management of
meningococcal disease. Infect Dis Clin North Am.
1999;13:661-84.[ go to PubMed ]