Delay in Administration of Antibiotics Causes Septic Shock and Death of 17-month-old Girl

2020 Medical Malpractice Case Report
By Attorney Krysia J. Syska
Suffolk Superior Court
Boston, Massachusetts

Medical malpractice lawsuit settlement is $1.5 million when antibiotic order is not clearly communicated during hand-off

Plaintiff’s minor decedent was born with polycystic kidney disease requiring peritoneal dialysis and left nephrectomy. She also had Caroli disease and cholangitis. Since her birth she frequently developed infections requiring the need for IV or oral antibiotics.

On 3/9/17 the she was evaluated in the ED for a four-day history of fever. She was smiling and interacting but was short of breath, tachypneic, and tachycardic. Her history of recurrent infections and sepsis/bacteremia twice in the past year were noted. The differential diagnosis in the ED included viral and bacterial infections. The plan included repeat blood cultures, complete blood count, chemistry, and a chest x-ray. She was to be admitted to the renal floor. On 3/10/17 at 12:58 A.M., it was noted that a blood culture had been sent.

That morning, she was noted to have respiratory distress, with grunting and flaring, and she appeared more tired on examination. Transfer to the ICU for respiratory support was planned. Her blood cultures had been negative and there was low suspicion for an occult infection however the plan was to send peritoneal dialysis fluid for cell count and culture.

An order for Zosyn antibiotic coverage was placed in her chart at 11:21 AM. However, at or around the same time a verbal order was given instructing the nurse to hold antibiotics until peritoneal fluid was obtained for cell count and/or culture. This verbal order to hold was never changed despite the fluid draw being obtained. Over the course of the next 14 hours the minor decedent’s condition deteriorated and she required intubation. She became increasingly hypotensive and suffered a PEA arrest and was placed on ECMO. Culture of the PD fluid revealed bacterial infection and antibiotic coverage was assessed revealing no antibiotics had ever been administered. Her first dose of antibiotics was given at 1:44 A.M. Unfortunately, by this time she was in septic shock with multiorgan system failure. She passed away later that day.

The hospital’s investigation reported that antibiotics were first ordered on transfer to the ICU, however, during hand-off the verbal order to hold the medication was not documented or clearly understood. There was no conversation to clarify communication between and within teams as to when the antibiotics could be administered. The lack of clarity and communication between the ED, ICU and Renal service was a contributing factor in the child’s death.

The parties were able to resolve the matter for $1,500,000 after the filing of the claim but prior to formal discovery being pursued.

Lubin & Meyer attorneys for the plaintiff: Andrew C. Meyer, Jr. and Krysia Syska.

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