Allegation
The parents of a 2-month-old alleged that the physician and advance practice clinician (APC) failed to administer the pneumococcal vaccine at the child’s 2- and 4-month well-child visits or inform the parents it was unavailable and could be obtained elsewhere. The child later developed pneumococcal meningitis.
Case Details
A healthy male infant presented for his two-month well-child visit and received several recommended vaccines; however, PCV13 was not administered due to stocking issues. The medical record documented the need for vaccines, review of side effects, and vaccine information statements (VIS). The vaccine record showed DTaP/hepatitis B/polio, rotavirus, and Hib were given. The plan stated, “will catch pneumococcal vaccine at the next visit since out of stock.” A discharge summary advised the parents that the next well-child visit should occur at four months of age. However, the four-month well-child visit was never scheduled.
Two months later, the patient presented to urgent care with a persistent cough, tested negative for RSV and COVID, and was discharged home. One week later, the patient returned for a sick visit with the same APC for vomiting after every feeding and nasal congestion. Examination noted rhinorrhea, nasal congestion, and intermittent congestion sounds. The patient’s temperature was 98.2, weight 14 lb. 8 oz, clear nares, moist mucous membranes, normal respiratory effort, no retractions or tachypnea, and clear lungs with equal breath sounds and no rales, rhonchi, or wheezes. Dry skin with erythematous patches and scaling was noted, and the patient was diagnosed with eczema and prescribed triamcinolone twice daily. The parents were advised to provide small, frequent feedings, elevate the head of the bed, use medication to neutralize regurgitated material, and try soy samples. The parents were instructed to call if the infant did not improve within the next two days.
Forty-five days later, the patient developed seizure activity and presented to the ED with a white blood cell count of 17.7. Cultures showed gram-positive bacilli, gram-positive cocci, and preliminary Streptococcus pneumoniae. The patient received lorazepam and levetiracetam and was started on IV antibiotics. After the seizures resolved, he was transferred by air to a larger facility, where a spinal tap was positive for pneumococcal meningitis.
Expert Testimony and Resolution
Plaintiff’s experts testified that PCV13 should have been administered at the two-month visit and that, if the vaccine was out of stock, the parents should have been informed immediately so timely vaccination could be arranged elsewhere. Experts opined that if PCV13 had been administered the patient most likely would have avoided meningitis.
Although the patient has since fully recovered, the parents stated during deposition that they were never informed the clinic was out of PCV13 and that the vaccine was not administered to the patient. As a result, the case was settled.
Risk Reduction Strategies
Notify patients of vaccine shortages.
Conclusion
This case illustrates how a seemingly routine operational issue—vaccine stock shortage—can evolve into a significant patient safety issue and liability when communication, documentation, and follow-up systems fail to close the loop. While the practice documented that the pneumococcal vaccine would be given later, the case focuses on whether the family understood their child remained incompletely immunized and whether reasonable steps were taken to ensure timely vaccination occurred elsewhere or at a subsequent visit.
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