Closed Claim Study — Failure to prescribe appropriate antibiotic

April 5th, 2013

by Louise Walling and Laura Hale Brockway, ELS

Presentation
On September 23, a 39-year-old man came to his family physician with complaints of a skin lesion on the right side of his head. The patient reported redness, pain, and puss discharge from the lesion for four days.

Physician action
The patient was seen by the physician’s assistant (PA). She examined the patient and documented that the lesion was approximately 1×1 cm, and was red and inflamed. The center of the lesion was scabbed with mild bloody exudate. The PA obtained a culture of the lesion and sent it off to the lab. The culture results revealed Methicillin-resistant Staphylococcus Aureus (MRSA), sensitive to sulfamethoxazole and trimethoprim.

The patient was prescribed sulfamethoxazole and trimethoprim, two pills, twice a day for 14 days and mupirocin ointment. He was given a handout about staph infections and told to return to the clinic in seven days. The PA did not incise and pack the lesion since the patient popped the lesion before the visit.

The patient returned to the clinic on October 2 and was seen by the PA. He complained of diarrhea and an episode of vomiting that morning. The patient’s vital signs were normal, his heart rate was regular, and his lungs were clear. He tested positive for Influenza Type A. The PA prescribed diphenoxylate/atropine, promethazine, and zanamivir inhalations.

Returning to the clinic again on October 11, the patient was seen by the family physician. He documented that the patient’s vital signs were normal and the scalp lesion was crusted and healing. The patient had completed his sulfamethoxazole and trimethoprim prescription and appeared to be recovering from the flu.

The patient was seen again at the clinic on October 28. He complained of right groin and leg pain. The patient reported that eight days earlier he had stepped in a hole while mowing the lawn and this caused his leg pain. The pain increased with walking and sleeping and the patient was using a cane to walk. The family physician suspected a pulled muscle and prescribed methylprednisolone, anti-inflammatories, and hydrocodone. He documented that if there was no change in the patient’s condition, he would order x-rays.

The patient’s leg pain continued and he returned to the family physician on October 31. The patient reported the pain was 6 out of 10 and he was walking with a limp. X-rays of the hip and femur were obtained and the results were negative. The family physician diagnosed a pulled muscle, told the patient to continue his medication, and ordered physical therapy. He planned to refer the patient to an orthopedic surgeon if he was not better in a week.

On November 2, the patient’s father contacted the clinic indicating that his son was incoherent and in terrible pain. The father was instructed to take the patient to the emergency department (ED). The patient coded in the ED, but was successfully revived and placed in ICU. Multiple specialists examined the patient and he was found to have multisystem organ failure due to suspected sepsis. Extensive efforts to save the patient’s life were unsuccessful. He died on November 3. An autopsy determined the cause of death to be from staphylococcal bronchopneumonia complicated by myocarditis.

Allegations
A lawsuit was filed against the family physician alleging failure to timely diagnose a MRSA staph infection and provide the appropriate antibiotic coverage.

Legal implications
The plaintiff’s expert claimed the patient’s MRSA scalp lesion was improperly treated and this led to the patient’s pneumonia and death. Specifically, the expert alleged that the lesion should have been incised and packed. He criticized the choice of sulfamethoxazole/trimethoprim and said vancomycin or clindamycin should have been used to treat the infection. Further, the MRSA infection was spreading to the blood and organs of the patient and the subsequent leg complaints were a symptom of the ongoing infection. This should have prompted the family physician to hospitalize the patient so he could receive intravenous antibiotics.

Defense experts pointed out that the patient’s MRSA infection on his head was sensitive to sulfamethoxazole/trimethoprim and the decision to prescribe this antibiotic was appropriate. There was evidence that the scalp lesion was improving with treatment. During the five visits from September 23 to October 31, the patient’s vital signs were stable and he did not have any fever.

Regarding the complaint of groin pain, there was a reasonable explanation in that the patient reported he stepped in a hole while mowing the yard. Defense experts believed the MRSA infection on the head resolved and the patient developed a separate subsequent infection that led to his death. It was unlikely that a patient with a systemic MRSA infection would be out mowing the yard and as active as the patient was in the days before his death. The medical examiner did not autopsy the patient’s legs, so there was no way to know if the leg pain was associated with the staph infection.

Disposition
This case was taken to trial and the jury reached a verdict in favor of the family physician.

Risk management considerations
The outcome of this case is viewed as a success for the defendant and it is useful to feature a claim that concluded with a jury exoneration of the defendant. However, this case still offers the opportunity to comment on some practice protocols that could be improved.

Two physicians who reviewed this case for the defense were critical of the family physician’s documentation, which was described as “indecipherable.” The records were also incomplete as to examination and reasoning for specific treatment or lack thereof. According to the Texas Medical Board rules for medical records, “Each licensed physician of the board shall maintain an adequate medical record for each patient that is complete, contemporaneous and legible.”

Illegible handwriting and incomplete record keeping are common weaknesses. Documentation or lack thereof can be subject to broad interpretations of actual meaning as well as the quality of patient care. A plaintiff’s attorney may use this to question
whether the physician was within the standard of care. All entries in a medical record need to be complete and legible.

Louise Walling can be reached at louise-walling@tmlt.org and Laura Hale Brockway can be reached at laura-brockway@tmlt.org.

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