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This podcast is an episode of Case Studies. You can find other episodes and subscribe using the links to the left.

Despite multiple visits to her PCP, a 30-year-old woman without a spleen was never given prophylactic antibiotics or told the risks of a high fever. A mishandled telephone triage delayed her trip to the ER, and the resulting pneumococcal sepsis led to permanent disabilities and a $1 million-plus settlement.

This podcast is an episode of Case Studies. You can find other episodes and subscribe using the links to the left.

Guest Commentator: Rich Parker, MD, Beth Israel Deaconess Care Organization


A 30-year-old female began care at a new primary care practice. At her first visit, the nurse practitioner (NP) noted that the patient had a splenectomy at age 10, secondary to mononucleosis, followed by pneumococcal vaccine. A history of hay fever was also noted, and the NP gave the patient prescriptions for Claritin and Flonase.

At a follow up visit two months later, she received a full exam by her new PCP, who also noted her history of mononucleosis and splenectomy. Other than a tetanus booster, no other immunizations were noted or discussed at this visit, nor during the next 13 months, when the patient was seen episodically for a work-required physical exam and some minor health issues.

Eight months after her last visit to the primary care practice, the patient attempted to call her doctor for a high fever of 105o, flu-like symptoms, and a 30-minute nose bleed. Because it was after hours, her call was transferred to a local trauma center nurse who surmised she had the flu, recommended ibuprofen; she told the patient that the center would re-open the following day at noon. But the next morning, with worsened symptoms, the patient was taken to a local Emergency Department. With a blood culture positive for streptococcus pneumonia, she was diagnosed with pneumococcal sepsis, started on antibiotics, and transferred to a tertiary hospital. She required a lengthy hospitalization due to compartment syndrome in both legs, and that led to partial amputations of both feet. She is now permanently in a wheelchair, requires treatment for recurrent osteomyelitis, and suffers from anxiety and depressive disorder.

The patient sued her PCP, alleging he failed to adequately evaluate and prevent her condition, and the case was settled for more than a million dollars.

To discuss the patient safety and risk management aspects of this case, we are joined by Dr. Rich Parker. Dr. Parker was a primary care doctor for many years, and is now Chief Medical Officer for Beth Israel Deaconess Care Organization in Boston.

Q) Dr. Parker, thank you for joining us.

A) My pleasure.

Q) Where do you think this case really started to go wrong?

A) This case, like lots of malpractice cases with bad outcomes, has a series of errors and a series of opportunities where things could have been corrected. I think this case started to go wrong with apparently the lack of knowledge on the part of the doctor and nurse practitioner of the risks for an asplenic patient.

Q) Why do you think that’s happening?

A) This is a curious phenomenon that I’ve noticed for a number of years that for some reason many doctors either didn’t adequately learn or seem to have forgotten the risks of the asplenic patient and in the routine care, the need to educate the patient and give them prophylactic antibiotics has been missed.

Q) So this kind of looked like a routine visit and some things really weren’t done.

A) This patient came in for a couple of routine visits, which were opportunities to educate the patient about her risk and give her prescriptions for antibiotics. That did not occur. That then set the foundation for the problems that occurred later in this case.

Q) Because the patient wasn’t aware that they needed to do something when this fever developed.

A) Correct. When the patient herself called with a very high fever, she did not volunteer to the person on the phone, ‘by the way, I don’t have a spleen,’ which certainly would have tipped off the phone triage person of the high risk.

Q) There were also some issues in how the phone call was managed overnight.

A) Right, so in this case, unfortunately, the patient called in the evening; she reported a fever of 105, which is very worrisome, with flu-like symptoms and a nosebleed. Unfortunately, the person who took the call did not have access to her medical record or did not use access to the medical record, and because the patient didn’t tell the nurse that she was asplenic, the nurse didn’t ask any probing questions about underlying medical conditions that would make that fever in context a far more worrisome event. We know what happened.

Q) If you look at how to work into the system a better risk prevention approach to this, what kinds of things can be done at the practice level?

A) In a practice with a solo practitioner, it is extremely difficult—though not impossible—to leverage information technology. In larger practices, they have a little more resources available to them. I know, for example, in the practice I used to work in, there was a registry for patients who were asplenic and that is a wonderful safety net to have for all the providers. All those patients are in a registry and somebody can look through or run that registry every year and make certain people are up to date on their vaccinations, that they are up to date with an antibiotic prescription, and that if they have a new provider, the new provider is aware of their diagnosis.

Q) More of a population management approach.

A) Exactly. I just would like to reiterate that phone triage is a little bit science and a little bit art, and in this case sadly, the person taking the call did not appear to ask enough probing questions for someone who presents with a fever of 105. And perhaps if a few probing questions had been asked, maybe even one question, such as, ‘do you have any underlying medical conditions that I ought to know about,’ perhaps this case could have had a better outcome.

Q) Thank you, Dr. Rich Parker, Chief Medical Officer at Beth Israel Deaconess Care Organization. I’m Tom Augello.

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About the series

Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.


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