New York University doctors miss signs of fatal illness, part II

Earlier in the week, we covered the tragic story of how a boy's misdiagnosis cost him his life. The 12-year-old had gone to New York University Langone Medical Center after his family physician said he had the flu and needed to be rehydrated. Instead, he had developed a bacterial infection from a cut in his arm that quickly led to a fatal septic crisis because of some very simple medical errors.

When the 12-year-old got to the hospital with his family, he received an anti-nausea drug and had three vials of blood taken for lab reports. Upon being admitted to the hospital, the boy had two of eight symptoms of sepsis, but two hours later, right before being discharged, he had three.

The Langone Medical Center is one of many New York-area hospitals that is part of a program to better combat sepsis. As part of the program, a hospital is supposed to start administering sepsis treatment the moment someone shows three signs of sepsis. Though the 12-year-old was showing the necessary number of signs, his discharge papers had already been printed and the family was waiting for some final instructions before leaving.

What may be the biggest medical errors associated with this case, however, is that later in the evening the boy's labs came back with several indications that he was fighting a serious bacterial infection. Had doctors missed the signs of a Group A streptococcus infection previously, this lab work should have immediately alerted them. Unfortunately, no one called the family and it wasn't until his mother and father brought him back in that physicians finally realized he was struggling with sepsis. By this point, however, it was too late to save the boy.

Source: The New York Times, "An Infection, Unnoticed, Turns Unstoppable," Jim Dwyer, July 11, 2012


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