A Lifetime of Risk

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This case study was put together by our partners at CRICO and was written by Debbie LaValley, BSN, RN


A 30-year-old woman with history of childhood splenectomy suffered a life-threatening infection.

Key Lessons
  • Primary care physicians should be prompted to give booster vaccines to asplenic patients.
  • An annual exam is an ideal time to review a patient’s history and any educational aspects of his or her care.
  • Verify that your telephone triage and coverage service adequately handles patient calls.
Clinical Sequence
  • A 30-year-old female began care under a new primary care physician (PCP). At her first visit, the nurse practitioner (NP) noted that the patient had a splenectomy at age 10 (secondary to mononucleosis) followed by a pneumococcal vaccine. A history of hay fever was also noted, and the NP gave the patient prescriptions for Claritin and Flonase.
  • Two months later, the patient had a full exam by her PCP, who also noted her history of mononucleosis and splenectomy. Other than a tetanus booster, no other immunizations were noted or discussed at this visit. During the next 13 months, the patient was seen for a work-required physical examination and some minor health issues. During that period, the patient received no vaccines, nor was discussion of vaccination documented in her record.
  • Eight months later (at Christmastime) the patient attempted to call her PCP for a high fever of 105o, flu-like symptoms, and a 30-minute nose bleed. Her call was transferred to a local trauma center nurse who surmised she had the flu, recommended ibuprofen, and informed the patient that the center would re-open the following day at noon.
  • The next morning, with worsened symptoms, the patient was taken to a local Emergency Department. With a blood culture positive for streptococcus pneumonia, she was diagnosed with pneumococcal sepsis, started on antibiotics, and transferred to a tertiary hospital. She required a lengthy hospitalization due to compartment syndrome in both legs, which led to partial amputations of both feet. She now has a permanent disability (wheelchair-bound), requires treatment for recurrent osteomyelitis, and suffers from anxiety and depressive disorder.

The patient alleged her PCP failed to adequately evaluate and prevent her condition.


This case was settled for more than $1 million.

Discussion Points

Process Failures
  1. The organization lacked a mechanism to capture and track multiple alerts that might have prevented the error.
  2. Clinicians were unaware of recent literature relevant to the care in question.
  3. The organization lacked a policy or protocol related to pneumococcal vaccines for asplenic patients.
  4. There was a failure to order medication, which in this case was the pneumococcal vaccine.
Clinical Judgment

Risk: Asplenic patients are unable to develop antibodies to prevent various infections, specifically pneumococcal viruses, meningitis, and influenza.

Recommendation: PCPs should be prompted to give booster vaccines to asplenic patients every five years after the initial administration of the vaccine. Empiric prophylactic antibiotic treatment should be given for any sign of infection.

Opportunity: Some physician practices have begun to use the concept of panel management; a set of medical interventions are applied reliably to a defined population of patients as a panel. Often electronic data are used to first identify asplenic patients and, then, clinical staff reach out to these patients to arrange for nurse-run appointments to receive necessary vaccinations, antibiotic prescriptions and education.


Risk: This patient was either unaware of the need for periodic vaccination, or she was reluctant to assert that need to the NP or PCP

Recommendation: Office practices should have a means of keeping a patient’s medical history and problem list up-to-date and easily accessible to the provider. An annual exam is a good time to review with patients their history and any educational aspects of their care. All educational discussions should be documented in the medical record.

Opportunity: Decision support tools for electronic medical records may be able to include automated scheduling reminders regarding immunization boosters.


Risk: Over the course of four visits, the practitioner did not inquire about a vaccine in a post-splenectomy patient.

Recommendation: In practices where NPs prescribe antibiotics, order work-ups for patients with signs and symptoms of an infection, and administer vaccinations, it is the PCP’s role to supervise and sign off on any medications/vaccinations that would be administered to a patient.

Opportunity: Periodic review of your organization’s policies and procedures for mid-level provider supervision serves to ensure compliance.


Risk: The patient was unable to reach her PCP when her symptoms began. Although her call was transferred to a covering provider, the trauma center nurse did not adequately assess the severity of her symptoms.

Recommendation: Verify that your telephone triage/coverage service adequately handles patient calls: listening intently without rushing or interrupting them, followed by open-ended questions. Do they have access to the patient’s record? Do they err on the side of either bringing the patient into the office to be seen or sending him or her to the ED for evaluation?

Additional Materials

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