Deadly Mistakes

This morning I got to work to find out that one of my patients, a young woman in her 30s who was neutropenic after getting chemotherapy, had been sent to the unit. She had spiked a fever overnight and become hypotensive, which given her neutropenic state wasn't too surprising. She'd first shown signs of infection four days ago, and we'd put her on vanco, Zosyn, and flagyl to treat her empirically. Or at least, I thought we did. Her blood had grown zosyn-sensitive Klebsiella, and I remember thinking, "Oh good, at least she has coverage for it." Then when I spoke to the night float, he said, "You know, she only got a one-time dose of vanco and flagyl four days ago, and hasn't had any since. The only antibiotic she'd been getting was Zosyn."

To say that I was stunned would be an understatement. I can't even describe what I felt when I heard him say that: it was a combination of shock, horror, worry, and fear. Definitely fear. We put our patients' medication lists on a Word document and copy them onto the progress notes everyday, and even though I put my med student and intern in charge of updating those lists, sometimes things aren't done. When our attending had told us to add broad spectrum Abx to this patient's med list, we added it onto the Word document without checking the EMR to see if it was actually being ordered. And all this time, we believed the patient was getting broad spectrum antibiotics when she wasn't. And now she's in the MICU on 2 pressors, intubated and septic, unlikely to survive the remainder of the week unless she really recovers.

It's hard to say who was at fault. The person who put in the abx orders as a one-time stat dose instead of a standing dose had only been at this hospital for 2 months and probably didn't know better. The medical student who's supposed to update the medication list each day never saw that the antibiotics had fallen out of the computer. And I, the resident, have been so busy doing admissions, trying to oversee a capped service, and keeping things in order that I never double-checked the computer to make sure she was getting her abx. Even the patient did not help matters by refusing blood cultures over the weekend (they drew stat cultures in the MICU and it grew out gram negatives within 8 hrs) I felt sick all morning and couldn't help but feel guilty over everything that happened. More so because I am strongly considering applying for a heme-onc fellowship and plan to ask my attendings for rec letters. Would they even look at my application after what happened? Fortunately the attending never once blamed any particular person for this, but I knew very well that that if something like this had happened to a patient on the heart failure service, the heart failure attendings would have done everything in their power to get me kicked out of the residency program. After all, this was a matter of life and death.

I went to see the patient later in the unit; by then she was intubated and had a central line and art line. All she wanted these past few days was to get better and go home to be with her kids. And now she might not survive. *sigh* Hoping she gets through this.