Failure to timely transfer patient
A nine-month-old patient was diagnosed with an upper respiratory infection (URI) and prescribed prednisolone and medication for cough and nasal congestion. Later that evening, the patient was brought to the ED with a worsening condition.
Failure to timely transfer patient
A nine-month-old patient was diagnosed with an upper respiratory infection (URI) and prescribed prednisolone and medication for cough and nasal congestion. Later that evening, the patient was brought to the ED with a worsening condition.
Presentation
A male infant was born on November 27, 2021, and tested positive for COVID-19 sixteen days later. For the next six months, the patient struggled with poor weight gain, a cow’s milk protein allergy, and gastroesophageal reflux.
Physician action
On September 12, 2022, the patient was seen by Pediatrician A for a nine-month well-child visit. He was diagnosed with an upper respiratory infection (URI) and prescribed prednisolone and medication for cough and nasal congestion.
Later that evening, the patient was brought to the emergency department (ED) at Hospital A for worsening cough and nasal congestion. The results of the lung exam were normal, but the chest x-ray was consistent with bronchiolitis. The patient was prescribed acetaminophen for fever and sent home.
On September 14, the patient’s mother brought him back to the ED because he had a worsening cough, wheezing, and increased difficulty breathing. Pediatrician B assessed the patient in the ED and diagnosed acute respiratory distress and hypoxia secondary to parainfluenza and rhinovirus.
The patient was admitted to the hospital under the care of Pediatrician B and given albuterol and ipratropium bromide. He was placed on a 2-liter nasal cannula to maintain adequate oxygenation.
The next day, it was noted that the patient was breathing more easily but still required supplemental oxygen.
When Pediatrician B saw the patient again on September 16, his condition had deteriorated. Pediatrician B planned to start antibiotics and arrange for transfer to a hospital that could provide a higher level of care. Pediatrician B left the hospital after putting in the orders.
That morning, at 9:15 a.m., the transfer center began looking for a placement at other hospitals. They found a hospital willing to accept the patient, but not until 11:30 a.m. Around noon, before the transfer to Hospital B was carried out, the patient’s respiratory status rapidly worsened and an ED physician was called to intubate.
A repeat chest x-ray showed interval progression of bilateral moderate to severe pneumonic opacities. The patient was intubated, but his condition continued to deteriorate. He was airlifted to Hospital B at 3:30 p.m.
At Hospital B, a repeat blood culture was drawn. Methicillin-resistant staphylococcus aureus (MRSA) was discovered two days later. The patient remained in critical condition and required full heart and lung support using an extracorporeal membrane oxygenation (ECMO) machine. Over the next week, the patient showed some small signs of cardiac improvement.
On September 24, the patient’s condition worsened significantly. After a discussion with the ICU team, the parents decided to withdraw life support. The patient died later that day.
Allegations
A lawsuit was filed against Pediatrician B alleging failure to properly assess the patient’s medical condition and failure to make timely attempts to transfer him to a more suitable hospital.
Legal implications
Expert consultants for the defense were supportive of Pediatrician B’s actions. One stated that while Pediatrician B identified the need to transfer the patient on September 16, it is likely the outcome would have been the same even if the transfer had happened earlier in the morning. Unfortunately, the patient was infected with three separate viruses, and nothing in the patient’s labs suggested impending and aggressive MRSA infection.
Plaintiff’s experts stated that Pediatrician B breached the standard of care by leaving the hospital for three hours after deciding to transfer the patient to a higher level of care and not ensuring that an appropriate level of physician supervision and support were available, which allowed the patient to become hypoxic and decompensated to a crisis level. In addition, he should have expected that it would be difficult to find an available bed at another hospital. Rates of pediatric hospitalizations due to viral illnesses were especially high in 2022 and routine childhood viral infections were more severe than in years past. (1)
Disposition
This case was settled on behalf of Pediatrician B.
Risk management for pediatricians
About diagnostic errors
Source
- Michelson KA, Ramgopal S, Kociolek LK, et al. Children's Hospital Resource Utilization During the 2022 Viral Respiratory Surge. Pediatrics. June 13, 2024. Available at https://publications.aap.org/pediatrics/article/154/1/e2024065974/197491/Children-s-Hospital-Resource-Utilization-During?autologincheck=redirected.
Accessed March 4, 2026.
Disclaimer
Presentation
A male infant was born on November 27, 2021, and tested positive for COVID-19 sixteen days later. For the next six months, the patient struggled with poor weight gain, a cow’s milk protein allergy, and gastroesophageal reflux.
Physician action
On September 12, 2022, the patient was seen by Pediatrician A for a nine-month well-child visit. He was diagnosed with an upper respiratory infection (URI) and prescribed prednisolone and medication for cough and nasal congestion.
Later that evening, the patient was brought to the emergency department (ED) at Hospital A for worsening cough and nasal congestion. The results of the lung exam were normal, but the chest x-ray was consistent with bronchiolitis. The patient was prescribed acetaminophen for fever and sent home.
On September 14, the patient’s mother brought him back to the ED because he had a worsening cough, wheezing, and increased difficulty breathing. Pediatrician B assessed the patient in the ED and diagnosed acute respiratory distress and hypoxia secondary to parainfluenza and rhinovirus.
The patient was admitted to the hospital under the care of Pediatrician B and given albuterol and ipratropium bromide. He was placed on a 2-liter nasal cannula to maintain adequate oxygenation.
The next day, it was noted that the patient was breathing more easily but still required supplemental oxygen.
When Pediatrician B saw the patient again on September 16, his condition had deteriorated. Pediatrician B planned to start antibiotics and arrange for transfer to a hospital that could provide a higher level of care. Pediatrician B left the hospital after putting in the orders.
That morning, at 9:15 a.m., the transfer center began looking for a placement at other hospitals. They found a hospital willing to accept the patient, but not until 11:30 a.m. Around noon, before the transfer to Hospital B was carried out, the patient’s respiratory status rapidly worsened and an ED physician was called to intubate.
A repeat chest x-ray showed interval progression of bilateral moderate to severe pneumonic opacities. The patient was intubated, but his condition continued to deteriorate. He was airlifted to Hospital B at 3:30 p.m.
At Hospital B, a repeat blood culture was drawn. Methicillin-resistant staphylococcus aureus (MRSA) was discovered two days later. The patient remained in critical condition and required full heart and lung support using an extracorporeal membrane oxygenation (ECMO) machine. Over the next week, the patient showed some small signs of cardiac improvement.
On September 24, the patient’s condition worsened significantly. After a discussion with the ICU team, the parents decided to withdraw life support. The patient died later that day.
Allegations
A lawsuit was filed against Pediatrician B alleging failure to properly assess the patient’s medical condition and failure to make timely attempts to transfer him to a more suitable hospital.
Legal implications
Expert consultants for the defense were supportive of Pediatrician B’s actions. One stated that while Pediatrician B identified the need to transfer the patient on September 16, it is likely the outcome would have been the same even if the transfer had happened earlier in the morning. Unfortunately, the patient was infected with three separate viruses, and nothing in the patient’s labs suggested impending and aggressive MRSA infection.
Plaintiff’s experts stated that Pediatrician B breached the standard of care by leaving the hospital for three hours after deciding to transfer the patient to a higher level of care and not ensuring that an appropriate level of physician supervision and support were available, which allowed the patient to become hypoxic and decompensated to a crisis level. In addition, he should have expected that it would be difficult to find an available bed at another hospital. Rates of pediatric hospitalizations due to viral illnesses were especially high in 2022 and routine childhood viral infections were more severe than in years past. (1)
Disposition
This case was settled on behalf of Pediatrician B.
Risk management for pediatricians
About diagnostic errors
Source
- Michelson KA, Ramgopal S, Kociolek LK, et al. Children's Hospital Resource Utilization During the 2022 Viral Respiratory Surge. Pediatrics. June 13, 2024. Available at https://publications.aap.org/pediatrics/article/154/1/e2024065974/197491/Children-s-Hospital-Resource-Utilization-During?autologincheck=redirected.
Accessed March 4, 2026.
Disclaimer
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