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. He was diagnosed with a thoracic strain, given IM morphine, and discharged home.

Four days later, the patient returned to the ED, 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 Fahrenheit. 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 scan 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.

Documentation at 1:30 PM indicated the patient’s 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 asked for 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 to the bathroom. He reported 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 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 attempted to find another physician when the patient-physician relationship deteriorated.

Plaintiff’s Case

The hospitalist had a duty to perform a neurological examination. If the patient refused to be treated and asked for a different physician, the hospitalist should have ordered an immediate neurological consult and found another hospitalist to provide care.

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

Patient Safety Strategies

Implement strategies to standardize and improve communication processes:

• Develop communication guidelines for transfer of patient care between practitioners. Guidelines will promote detailed 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 should have been discussed—in particular, testing to address the patient’s leg weakness.
• Use standardized communication techniques for both nurse and physician communications. Consider implementing the Institute for Healthcare Improvement’s SBAR tool (Situation, Background, Assessment, and Recommendation) or a similar standardized communication process. These types of tools provide a framework for relevant and clear information about a patient’s condition.
• Promote a culture of safety among caregivers that addresses communication and language barriers. Failures to communicate will continue unless team members feel safe in expressing difficulties in understanding other team members. In this case, the nurses had noted that a language barrier with the physician had resulted in an inability to understand him and a reluctance to call him about patients. The hospital staff 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, have processes in place to facilitate communication, or transfer the patient’s care to another practitioner. Transfer care in a timely manner, with verbal interaction between practitioners to ensure that vital information is communicated. In the case scenario presented here, if care had 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,” or contact the Department of Patient Safety at (800) 421-2368 or by email.