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Missed test result

01 September 2008

Rosie was three years old when she was brought into the A&E department with a high temperature. Rosie’s mother, Mrs C, had given her 200 mg of paracetamol oral suspension and 100 mg of ibuprofen oral suspension 20 minutes before bringing her to the A&E department.

On arrival, Rosie was still pyrexial, with a temperature of 38.6°C. After a thorough history and examination, emergency medicine junior doctor, Dr K, performed dipstick urinalysis on Rosie’s urine before sending it to microbiology for microscopy, culture and sensitivity. The dipstick showed 2+ leucocytes and a trace of protein. The next morning, microbiology rang Rosie’s results through to the A & E department as there was a high white cell count. This result was not passed on to the paediatric ward. On the paediatric ward, paediatric consultant Dr B diagnosed Rosie with a viral infection and discharged her home without checking the results server. The next day the printed microbiology report arrived on the ward, was signed as received by paediatric junior doctor, Dr P, and duly filed in Rosie’s notes.

A month later Rosie developed dysuria and enuresis and Mr C took her to see her GP, Dr G. After examining Rosie, Dr G diagnosed a urinary tract infection and prescribed a week’s course of trimethoprim. Dr G asked Mr C to bring in a clean catch urine sample taken before the first dose of trimethoprim so he could send it to microbiology. Mr C brought the sample in later that evening and a UTI was confirmed several days later. Dr G had no record of Rosie’s previous admission to hospital and Mr C had not mentioned it, so, assuming this to be Rosie’s first episode of UTI, Dr G did not refer her for further investigations.

Almost two years later, Rosie developed dysuria, enuresis, pyrexia, loin pain and vomiting. She again took Rosie to the A&E department. Recognising Rosie as acutely unwell, she was admitted directly to the  paediatric department. Rosie’s old microbiology results were then found on the hospital’s results server and it was noticed that the first urine microscopy had shown a high white blood cell count and culture had shown bacterial growth. Renal ultrasound and DMSA radioisotope scans were arranged and showed severe renal scarring. A micturating cystourethrogram was then performed and demonstrated the presence of bilateral vesicoureteric reflux. Mr and Mrs C complained to the hospital and the GP practice for failing to diagnose the first urinary tract infection, failing to arrange the appropriate scans and failing to start Rosie on prophylactic antibiotics.

Learning points

  • This case stresses the importance of having in place a good system for checking all the results of hospital investigations and communicating these results with primary care practitioners.
  • There was a failure of the A&E department system to ensure that abnormal results were communicated with the ward, both for the white cells found and then for positive growth. The results should have been made available for the discharge letter, and the junior doctors should have taken appropriate action in the ward.
  • With almost all results being available on hospital results servers, checking paper reports that arrive on the ward can be seen as unnecessary and tedious. However, this leads to important results that are not instantly available, such as microbiology, often going ignored, especially if the patient has been discharged.
  • All doctors are responsible for ensuring tests are checked and signed with appropriate action taken if necessary.
  • Never underestimate the value of taking a comprehensive history.
  • This case also shows the importance in putting in place a safety net, to help parents understand what they should do if symptoms recur.
  • Locally agreed guidelines on the management of a first UTI in pre-school children should be available. These should be followed, unless you are able to justify your reasons for not following them.
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