Delay in Treatment for Sepsis Results in Death of a Child

By ThinkReliability Staff

On April 1, 2012, a patient at a university medical center in New York died from sepsis.  The death was especially heartbreaking as the patient was 12 years old . . . and had been healthy just 4 days prior.  However, he had contracted a bacterial bloodstream infection (sepsis), which has a high mortality rate (nearly 40%, according to the United Hospital Fund) that grows with every passing hour.  (A study cited by the New York Times found that the survival rate decreases by 7.6% every hour before antibiotics are given.)  With response time so crucial to patient outcome, rapid action at every step of the process is required.

We can look at this incident in a visual root cause analysis, or Cause Map.  The purpose of this map is not to assign blame, but rather to discover and document causes in the hope of finding solutions to reduce the occurrence of this type of issue.

We begin with the impacts to the goals.  In this case, the patient safety goal was impacted due to a patient death.  Because of the high potential for emotional impact to providers, employees are also impacted.    The potential for a lawsuit is an impact to the organizational goal, and the initial misdiagnosis of the patient is an impact to the patient services goal.

We begin with the patient safety goal and ask “Why” questions to develop cause-and-effect relationships that will show all the causes of the incident.  The patient died of severe septic shock and insufficient intervention.  (Had intervention come earlier, the patient may have lived.)  The onset of the sepsis appears to have been a cut acquired at school, which was bandaged, but possibly not cleaned, likely due to the lack of severity of the initial injury.  Delay of treatment allowed the sepsis to overwhelm the immune system.  The treatment was delayed due to an initial misdiagnosis of dehydration.     Sepsis is particularly difficult to diagnose because many of its symptoms mirror symptoms of other more common ailments.  Information was not shared between providers – the child’s primary care pediatrician, parents, and the hospital staff, which may have contributed to the difficulty in diagnosis.  Test results taken at the hospital came in after discharge and were not shared by phone with the primary provider or parents.  Additionally, even after lab results from the hospital suggested that the white blood cell count was abnormally high, indicating infection, no action was taken.

From this very basic, high level map, at least four areas of specific improvement can be noted.  Protocol at the school for injuries that involve cuts – even if they seem minor – should include cleaning or disinfection.   The hospital should have – and follow – protocol for that specifies action to be taken upon receipt of lab results.   This protocol should include documenting and sharing test results with other providers and caregivers.  Because of the difficulty in diagnosing sepsis, and the importance of quick action, the United Hospital Fund is current developing a STOP Sepsis Collaborative, which aims to “reduce mortality in patients with severe sepsis and septic shock by implementing a protocol-based approach to case identification and rapid treatment”.  Ideally, implementation of the results of this collaborative will reduce the risk of patient death from a situation like this tragic case.

To view the Outline, event Timeline, Cause Map, and Solutions, please click “Download PDF” above.  Or click here to read more.