Failure to Diagnose Toxic Drug Reaction by Numerous Clinicians Ends in Tragedy

What happens when multiple practitioners fail to spot a fatal drug reaction?
What happens when multiple practitioners fail to spot a fatal drug reaction?

Often, medical malpractice cases are not the fault of just one practitioner. In many cases, there are several people who share responsibility for the medical negligence. This month's case looks at one of those situations. This case involved a whole system failure, involving numerous physicians and a hospital.

The patient, Mr. B, was a 52-year old husband and father of five. He worked as a computer programmer and was relatively healthy, seeing his primary care physician about once a year for check-ups, to monitor his hypertension, and for minor complaints. Mr. B most recently saw his PCP, Dr. F, 45, for a urinary tract infection and the physician prescribed Septra (trimethoprim and sulfamethoxazole). But a week later, Mr. B developed chills, fever and vomiting. He called Dr. F, who told him that it was likely a viral infection and he should feel better in a few days. The doctor told him to remain on the Septra.

But five days later, Mr. B had not improved. In fact, he was significantly worse. He had now developed a rash covering his body and a sore throat so severe that he could not speak. Unsure what to do, his wife took him to the emergency department of the local hospital. However, with five young children at home and no child care, she could only stay with her husband a short while and had to return home.

In the emergency department, staff noted that the patient's rash extended from his trunk up the back and to his neck and arms. Mr. B was unable to speak or provide information to the hospital's doctors, so hospital staff called his primary care physician, Dr. F.  Dr. F told the hospital staff that the patient had recently had a urinary tract infection, but did not inform the hospital's doctors that Mr. B was on Septra.

Mr. B was admitted to the hospital with a diagnosis of drug reaction, although at this point the hospital did not know what he was having a reaction to. Once admitted, he was seen by the hospital's infectious disease consultant, but the consultant did not take a history, as was required for a drug reaction. Mr. B still could not communicate, but neither the infectious disease consultant, the hospital physicians, nor Dr. F asked Mr. B's wife to retrieve his medicine bottles from home.

Shortly after being admitted to the hospital, Mr. B's condition worsened. His skin began to fall off. Hospital policy required that patients with skin reactions be seen by a dermatologist, however it was the weekend and no dermatologist was on call at the hospital. No outside dermatologist was brought in to see the patient. Another physician in the hospital diagnosed Mr. B as having Toxic Epidermal Necrolysis (TEN) syndrome and Stevens-Johnson syndrome (SJS).

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