26 February 2008

The Sequel

As follow-up to my post on error management in medicine, I dissect my own error for your education and edification and gratification...

Read it over at MedPage Today.


  1. I am commenting here because I am too lazy to log in at the other site. I wonder, with the advent of more shift-working docs, e.g. residents and hospitalists, that this situation is not ripe for becoming epidemic. It also illustrates my long-held conviction that medicine is a relentless taskmistress (don't ask why I think of her as female, being female myself) - one never gets a break - except, perhaps, that our errors mostly do not kill the patients.

  2. Um. What about the fact that nothing said bacterial meningitis at first?

    Are saying the previous doctor missed an ear infection which caused the spread of the bacteria to the brain which could have been prevented with antibiotics? All the kid would have had was probably 1 dose of PO antibiotic---would that have prevented a bacterial meningitis?

  3. K,

    What I am saying is that the kid probably already *had* meningitis when we saw him. We don't know because neither of us did a good exam. We know a perforated eardrum (not exactly subtle) was missed. Were there meningeal signs? If I'm tired and thinking "face pain" I might not check for nuchal rigidity. Since 12 hours later he already had ALOC, he certainly had early meningitis on presentation.

    It's equally likely that he would not have been diagnosed with meningitis even had we done a good exam. He was on steroids, which notoriously can mask disease.

    He did get a dose or two of antibiotics, which may account for his complete recovery. The point is that it was a fuck-up, and that we're very lucky he came back. Had he been left home alone, he probably would have been found dead the next morning.

  4. That's a scary case because of it's atypical presentation. But it's an easy mistake to make on your part with the simple assumption that the night doc did his job thoroughly and completely. If you don't make that assumption, you're going to have to spend the first 2 hours of every shift re-hashing everything that your colleagues have done and wasting a bunch of time. Do you think a quick HEENT exam might have caught anything like papiledema or some otitis/exudate? If he perfed an ear drum in 12-16 hours it seems like there might have been something in the otoscopic exam. But what do I know, I'm a second year med student.

    I'm glad everything came out all right with the patient and hope you don't get thrown under the bus for this one.