Delayed bacterial infection diagnosis leads to $9.5 million verdict
News: New parents noticed their 2-week-old child had missed some feedings and was not behaving normally. The parents then decided to bring the child to the emergency department of a nearby hospital. When the results from the blood test came back positive for Group B streptococcus (GBS), the child's parents were not informed immediately and neither was the child's pediatrician. The emergency department staff waited two days to inform the parents and the treating pediatrician that the child tested positive for GBS. Unfortunately, at this point, the infection spread quickly throughout the infant's system, reached her brain, and caused meningitis. By the time the parents eventually were told to bring the child back to the local hospital to admit the child, the child already had developed cerebral palsy, a permanently debilitating condition. The hospital settled the case. After an 11-day jury trial, the jury found the emergency nurse and the emergency department medical group liable for professional medical malpractice and awarded $9. 5 million in damages.
Background: The young child's parents brought the child to the emergency department of a nearby hospital after observing the child's decreased appetite and abnormal breathing patterns. The parents patiently waited six hours in the emergency department to find out what was wrong with their child. However, after a blood sample was drawn for further testing, the parents were told to return home with the child as it was very likely that the child was suffering only from a cold. Within hours, the blood results indicated that a bacterium was present in the vulnerable child's system. The hospital laboratory immediately called down to the hospital emergency department to relay the results: The gram stain tested positive for GBS. An emergency nurse was told the results, but tragically this information was not immediately provided to the emergency physician who evaluated the child.
Additionally, the emergency nurse failed to contact the parents or the child's pediatrician to inform them that bacteria was present in the child's bloodstream and ask that the child be brought back to the hospital for emergency medical treatment. When the emergency physician finally became aware of the blood culture results two days later, indicating that the GBS bacteria was present in the infant's blood, he advised the parents to bring the child back to the hospital to be admitted immediately.
GBS generally is carried in the intestines and lower genital tract. While normally not a serious problem for adults with well-developed immune systems, GBS does pose a significant danger to newborns. If GBS is carried by pregnant women, it becomes a danger to the infant during delivery. Most hospitals test women for GBS during prenatal care or during the early stages of labor. If present, antibiotic therapy is given to the mother, and the child is protected from developing the infection.
Unfortunately, by the time the parents were informed, the infection had developed into meningitis, and it caused seizures in the child's brain. The emergency physician and nurse delayed informing the parents about the lab results. By doing so, precious time was wasted, as the child urgently needed medical attention.
When the first test came back indicating that bacteria was in the child's blood, GBS should have been considered, and the child's parents should have been instructed to bring the child back to the emergency department immediately. Two days after initially bringing the child to the emergency department, the parents were informed that GBS can result in meningitis and that the problem needed to be addressed quickly now. By this point, it was too late, as the child already had suffered irreparable damage to her young body and brain. As instructed by the emergency physician, the parents brought the child to the hospital to be admitted. But after treatment long overdue, the parents were informed the child had developed cerebral palsy at the young age of less than three weeks old.
The parents subsequently brought suit against the hospital, the emergency department medical group, and the nurse overseeing the child's care in the emergency department. Prior to trial, there was a confidential settlement agreement with the hospital, but the case proceeded against the emergency department medical group and the emergency nurse. Ultimately, the emergency department medical group and the emergency nurse were held jointly and severally liable for the child's irreparable damages after an 11-day trial. The jury awarded the $9. 5 million in damages, which included $5 million for future medical bills and expenses, $1. 5 million awarded for lost earnings, and $3 million for non-economic damages, such as pain and suffering. However, pursuant to the law in the applicable state, non-economic damages are subject to a cap of $650,000.
What this means to you: While it is often difficult to keep track of timelines during emergency medical care, it is important that well established protocols be kept and maintained to ensure that patients and treating physicians are informed as soon as possible regarding time sensitive test results. Various hospitals have different systems in place for ensuring that results are provided to the right contact immediately; for example, time logs. In this case, the nurse responsible for contacting the parents and pediatrician about the test results allowed too much time to go by before informing someone. It is unfortunately not uncommon for test results to be overlooked once a patient leaves a busy emergency department. If the results are not directly recorded electronically into the emergency department chart, it is even more difficult to manage. They often are found later in either a miscellaneous file in the emergency department that no one has responsibility for, or returned to the medical record department to be filed in the emergency department chart at a later date. As electronic recordkeeping advances and improves, most systems are able to capture test results in the medical record as soon as available. But that does not negate the responsibility for someone to gather the results of ordered tests and bring them to the attention of the treating physician for follow-up orders. Medical staff rules and regulations typically require that the treating physician review the results of all tests ordered, even if the patient has been discharged. A nurse might be assigned the duty of bringing these results to the physician for review; however, it should not be the nurse's responsibility to decide if a test result is normal or abnormal. Unless the nurse has advanced practice credentials, such as a nurse practitioner or physician's assistant, the responsibility falls to the physician. However, once the physician determines that a test result is abnormal, he or she can delegate notification of the patient to the nurse. The physician should electronically sign that the results have been reviewed, and the nurse should document that the results were called in to the patient with additional instructions given if required.
Some electronic medical records come with an indicator, such as a red flag, that a new result has been received. The indicator remains until the result is signed off as being seen by the physician. These types of electronic alert systems work well to ensure that nothing is missed. Whatever system is in place to notify physicians and patients of test results, it needs to be monitored and tested periodically for accuracy and effectiveness. This point assumes added importance as electronic recordkeeping becomes increasingly common throughout all pivot points in the healthcare delivery system.
It is important to note that the nurse in charge of relaying the time sensitive lab results to the parents and pediatrician testified that she recalled "having concerns" about the infant and it had generally been her normal practice as a nurse to inform doctors of any problems or delays in a patient's treatment. An infant at two weeks of age is a prime target for becoming septic with GBS. The mother should have been questioned about being tested for GBS during her pregnancy. Given the danger of becoming ill very quickly, the child should have remained in the emergency department to receive emergent medical care until it was ruled out. This case is thus a strong example of how vital it is to stick to one's instincts as a medical professional. The nurse knew that the child was in danger of suffering severe and permanent damage based on the type of bacterial infection, so it is likely that the nurse knew in her professional experience that keeping a good track of the test results was exceptionally important to this child's treatment. Clinicians should use their medical experience, knowledge, and general practices to make sure that they follow the necessary procedures involved in medical care. They should have back-up systems in place for times when the electronic data is down. And they should follow through on the medical plan for the patient. If you are ordering a test, there must be a reason. That reason does not disappear when the patient leaves the office or facility. Clinicians need to understand how and when physicians are to be notified of pending test results and when and how any abnormal results will be communicated to the patient. While the nurse was culpable because of her oversight, the physician has the ultimate responsibility to complete the circle of care.
- Case No. CAL 11-08836 (Prince George County Circuit Court, Prince George County, MD), Nov. 22, 2013.