( 10 ) A teenage patient presented to the ED for complaints of abdominal pain and fever. Lab work was ordered, and IV fluids were administered. The abdominal CT scan was normal. An additional three liters of IV fluids were given. The blood pressure remained low, but the patient was discharged with an antibiotic for a possible UTI. The patient returned to the ED that same day with worsening symptoms. A chest X-ray revealed pneumonia. To assist with the differential diagnosis, which included sepsis, the physician wanted a gallbladder ultrasound that was unavailable at the hospital. The patient was instructed to proceed to another hospital for the ultrasound. The patient presented to the receiving hospital with tachycardia, hypotension, and a low O2 sat.The gallbladder ultrasound was normal. A chest CT revealed multifocal pneumonia. The patient remained hypotensive and was admitted to the ICU with a diagnosis of septic shock pneumonia. The patient died a few days later. The blood culture results and autopsy revealed a rare Fusobacterium infection. CASE STUDY #1: Infection Case Gone Wrong Delayed sepsis diagnosis and multiple handoffs result in teenager’s death. | HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys |