Communication Breakdowns Lead to Missed Spinal Epidural Abscess: Case Study

Michelle Swift, JD, RN, Senior Patient Safety Risk Manager, The Doctors Company

Analyses by The Doctors Company of over 25,000 closed malpractice claims repeatedly show that poor communication and communication breakdowns lead to patient harm and prompt malpractice claims. Consider the following case example.

Case Scenario

A 38-year-old male, a known IV drug user, came to the emergency department (ED) complaining of pain in his left shoulder and back. At that time, he was diagnosed with a thoracic strain, given IM morphine, and discharged home.

Four days later, the patient returned to the ED in the middle of the night, complaining he could not feel his legs and that he had blood in his urine. An examination revealed tenderness in the abdominal left lower quadrant and upper left side of his back. His temperature was 101 degrees F. Bladder catheterization yielded 1600 cc of urine. His laboratory tests showed a white blood count of 21.9, glucose 170, and a positive toxicology screen for methamphetamines. A CT revealed renal calculus with mild bilateral hydronephrosis. At 6:30 AM, the hospitalist was notified of the patient’s admission to the nursing unit. The working diagnoses were pyelonephritis, urinary retention, and urosepsis.

The hospitalist’s note in the medical record at 8:00 AM described the patient as a poor historian, uncooperative, and complaining of leg weakness, back pain, and bladder distention. Furthermore, cauda equina syndrome or nerve root compression could not be ruled out at that time.

It should be noted that English was not the hospitalist’s primary language. The nurses noted that this communication barrier resulted in an inability to understand the physician and that, in the past, it had led to a reluctance in calling the physician about patients.

Documentation at 1:30 PM indicated the patient’s current chief complaint was an inability to feel his legs. He appeared sleepy, experienced nausea and vomiting, and his abdomen was tender in all quadrants. Although there was some lower extremity paresthesia, the patient’s neurological status could not be reliably examined because he was uncooperative. The hospitalist believed the patient had other issues, including a possible acute neurologic insult. He ordered an MRI of the lumbosacral spine and a urology consult.

The lumbosacral MRI showed a minor disc herniation at L4-5 and degenerative changes at L5-S1. The urology consult noted that the hydronephrosis was not significant and could not explain the lower extremity weakness. The urologist agreed with antibiotics and suggested further neurological workup.

That evening the patient complained of increased pain in the abdomen and legs. He was given IV Dilaudid. At that time, the hospitalist’s note said that the patient refused examination and had requested another physician.

The next morning, the patient stated that his pain was out of control. He was medicated, and blood cultures at that time indicated gram-positive cocci infection. The newly assigned hospitalist was notified, and vancomycin was started.

That afternoon, the patient fell while being transported from the bed to the bathroom. He reported during this incident that he had no sensation in his legs. A stat thoracic MRI was obtained.

The thoracic MRI showed an epidural abscess with spinal cord compression from T3-T10. The patient was immediately taken to surgery for an evacuation of the abscess.

Postoperatively, the patient had no motor function or sensation of the lower extremities, and he was having difficulty swallowing. The patient was eventually discharged to a rehabilitation facility with a diagnosis of epidural abscess with a culture growing methicillin-sensitive Staphylococcus aureus. Months later, the patient remained confined to a wheelchair, showing some ability to stand with extra support.

The patient sued, alleging that the admitting hospitalist failed to diagnose a spinal epidural abscess, resulting in spinal nerve damage.

Defense’s Case

One defense expert was supportive of the care provided by the hospitalist and opined that the admitting diagnosis, initial labs, and medications were appropriate, given the patient’s symptoms. The patient’s lower extremity weakness was explained by his history of back trauma and pyelonephritis. A complete neurology exam to verify lower leg weakness would have helped, but the patient refused to allow the hospitalist to examine him.

Other experts, however, were critical that the thoracic MRI should have been obtained sooner, given the nondiagnostic MRI of the lumbosacral spine. In addition, the hospitalist should have clearly outlined attempts to find another physician when the patient-physician relationship was deteriorating.

Plaintiff’s Case 

The hospitalist had a duty to perform a neurological examination. If the patient refused to be treated by him, the hospitalist should have ordered an immediate neurological consult and found a new hospitalist to provide care.

The multiple communication breakdowns among providers and between the patient and provider contributed to the patient’s poor outcome.

Patient Safety Strategies

Implement the following strategies to standardize and improve communication processes:

  • Develop communication guidelines for transfer of patient care between providers. Guidelines will promote thorough communication of a patient’s condition when a patient is admitted to another service. In this case, the emergency medicine physician should have contacted the hospitalist and provided the patient’s history and condition. Further testing could have been discussed—in particular, addressing the patient’s leg weakness. 
  • Use standardized communication techniques for both nurse and physician communications. Consider the SBAR tool (Situation, Background, Assessment, and Recommendation) or a similar standardized communication process. Such a process provides relevant and clear information about a patient’s condition. 
  • Promote a safe culture when communication barriers exist. The language barrier among caregivers may have been a factor in the delay of care. Failures to communicate will continue unless team members feel safe in expressing a difficulty in understanding due to language or other communication barriers. The hospital and physician groups (e.g., hospitalist, emergency medicine, radiology) should collaborate to address barriers that hinder information exchange.
  • Develop protocols to address challenging patients and transfer of care. When the physician/patient interaction is impeded, either through language barriers or personality conflicts, processes need to be in place to use a translator to facilitate communication, or transfer the patient’s care to another provider. When care is transferred, it should be done in a timely manner with verbal interaction between practitioners to ensure that vital information is communicated. In this case, if care been transferred in a timely manner, further testing may have been ordered and the degree of injury may have been mitigated or avoided.

For additional information on communication and handoff strategies, see our articles, “Miscommunication and Hurried Handoffs Threaten Patient Safety” and “Patient Safety Strategies for Hospitalists.” You may also contact the Department of Patient Safety at patientsafety@thedoctors.com or (800) 421-2368.


The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J12652 01/21