Table 3. Summary of Major Errors Contributing to Potentially Preventable Sepsis-Associated Deaths and Specific Underlying Infections or Complicationsa.
| Major Error Category | Specific Infection or Complication |
|---|---|
| Delay in recognition of infection or sepsis, leading to delay in antibiotics or source control (n = 9) | Empyema (n = 1); enterococcal bacteremia (n = 1); necrotic bowel (n = 1); Pseudomonas aeruginosa pneumonia (n = 1); Staphylococcus aureus bacteremia (n = 4); Staphylococcus lugdunensis bacteremia (n = 1) |
| Infection or sepsis recognized but delay in antibiotics (n = 7) | Intra-abdominal infection (n = 1); necrotic bowel (n = 2); pneumonia, unknown pathogen (n = 2); P aeruginosa bacteremia (n = 1); sepsis of unclear source (n = 1) |
| Infection or sepsis recognized, timely antibiotics administered but inappropriate choice (n = 10) | Bacteroides fragilis bacteremia (no anaerobic coverage) (n = 1); Candida albicans bloodstream infection (no antifungal) (n = 1); Escherichia coli pneumonia (no gram-negative coverage) (n = 1); extended-spectrum beta-lactamase–producing E coli bacteremia (no carbapenem) (n = 1); Enterococcus faecalis bacteremia (no enterococcal coverage) (n = 1); methicillin-resistant S aureus bacteremia (no vancomycin) (n = 1); Mycoplasma pneumoniae encephalitis (no atypical coverage) (n = 1); Pneumocystis jiroveci pneumonia (no pneumocystis coverage) (n = 1); P aeruginosa pneumonia (no pseudomonal coverage) (n = 1); septic shock of unclear source (no gram-negative coverage, only vancomycin + azithromycin) |
| Infection or sepsis recognized but delay in source control (n = 7) | Chest tube for empyema (n = 1); percutaneous drainage of gangrenous gallbladder (n = 1); percutaneous drainage of intra-abdominal abscess (n = 1); removal of infected central line with S aureus bacteremia (n = 1); surgery for necrotic bowel (n = 3) |
| Potentially preventable hospital-acquired infection (n = 2) | Central line–associated bloodstream infection with C albicans (n = 1); peripheral intravenous catheter–associated septic thrombophlebitis with S aureus bacteremia (n = 1) |
| Procedural complication (n = 3) | Major bleeding after elective thoracic surgery (n = 1); major bleeding after paracentesis (n = 1); cardiac ischemia and myocardial infarction after elective arrhythmia ablation (n = 1) |
| Medication adverse event (n = 3) | Major bleeding from excessive oral anticoagulation (n = 2); chemotherapy adverse event (n = 1) |
| Other (n = 1) | Inadequate patient monitoring leading to delayed recognition of unstable arrhythmia (n = 1) |
a
There were 36 potentially preventable sepsis-associated deaths in the cohort. The total number of errors in the table (n = 42) exceeds 36 because several patients experienced multiple major errors.