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A 63-year-old man with benign prostatic hypertrophy and diabetes mellitus presents to the emergency department with gradual decrease in urine output for the past 1 week, and inability to urinate today. Over this time, he has developed abdominal pain and fullness. His medical history is otherwise unremarkable. His only medications are finasteride, terazosin, metformin, and a baby aspirin daily. On examination, his temperature is 99.8°F, blood pressure is 138/86 mm Hg, heart rate is 97 bpm, respiratory rate is 14/min, and pulse oximetry is 99% on room air. He appears uncomfortable but in no acute distress. His cardiopulmonary examination is unremarkable. He has suprapubic pain to palpation and dullness to percussion in the same region. He does not have costovertebral angle tenderness. Laboratory evaluation demonstrates WBCs of 13,000 cells/mm3. After repeated attempts to place a straight urinary catheter, a Coudé catheter is finally placed successfully with resultant 1 L of urine output. Urinalysis shows large hematuria, leukocyte esterase, and nitrites, with 10 to 50 WBCs/hpf. Serum chemistry is normal. Urine and blood cultures are drawn, and empiric ciprofloxacin is started intravenously.

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He is admitted for observation and discharged in less than 24 hours with an indwelling urinary catheter, a prescription for oral ciprofloxacin, and instructions to follow up with his primary care provider (PCP) in 24 to 48 hours. He is lost to follow-up and presents to the ED 1 week later with fever, hypotension, and acute kidney injury. His urinary catheter is no longer draining, but he cannot recall when it stopped doing so. Review of his chart shows that the urine and blood cultures drawn 1 week ago grew E. coli that were resistant to ciprofloxacin. He is admitted to the hospital and started on piperacillin–tazobactam intravenously for urosepsis.

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1. What type of medical error occurred?

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2. How could this error have been prevented? What could the inpatient physician (emergency department physician, PCP, hospital, patient) have done differently to prevent rehospitalization?

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Answers

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  1. Test follow-up error occurred, in which a test result that was pending at the time of discharge was not followed up. The patient had urine and blood cultures ordered and in process, which usually take at least 24 to 48 hours for a preliminary result, and up to 5 days for a final result. This patient stayed in the hospital for observation only, and thus was discharged in less than 24 hours. The case does not provide enough information to determine if an adequate handoff regarding the pending test result occurred and who would be responsible for following up on the final result with the patient. The positive blood and urine cultures indicated that the oral antibiotic prescribed at discharge would not provide adequate antimicrobial coverage. The result was potentially actionable in this case, meaning that the result would have changed the plan of management or, ...

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