Anna, a 4-year-old girl with a history of asthma, was taken by her parents to an urgent care clinic where she was diagnosed with an upper respiratory infection and streptococcal pharyngitis for which she was prescribed an antibiotic. Two days later, her parents brought her into the emergency
department (ED) after she began having trouble breathing despite using her asthma medications.

The child previously had visited the same ED over 30 times and had been admitted several times. The child arrived at the hospital at 2:00 AM and was seen by a team consisting of Dr E and Nurse R. Within 3 minutes of the patient’s arrival, Dr E ordered that the patient be given ipratropium and albuterol by nebulizer. By 2:11 AM, Nurse R had completed her triage assessment. She noted that Anna had labored breathing and was wheezing. Her pulse was 156 beats/min, respiration rate was 36, and pulse oximetry on room air was 91%. Twenty minutes later, Nurse R noted in the chart that Anna had tolerated the ipratropium and albuterol treatment well, with no adverse reactions, and that her respiratory status improved.

At approximately 2:30 AM, Dr E examined the child and determined that she no longer had signs of respiratory distress. She was breathing normally without the use of accessory muscles, and although she was wheezing, the doctor noted in the chart that the symptoms were “mild.”

At 2:45 AM the child, with her mother accompanying her, was taken to radiology for a chest radiograph. A half hour later, Nurse R noted that Anna was administered albuterol inhalation.


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At approximately 3:30 AM, Nurse R took the child’s vitals again. They were recorded in the chart as pulse rate, 145 beats/min; respiration rate, 34 breaths/min, and pulse oximetry level, 99%; however, the chart did not specify whether this rate was measured on room air or with supplemental oxygen. A short while later, Nurse R administered dexamethasone to the patient.

At 3:50 AM, Dr E reviewed Nurse R’s notes, Anna’s vital signs, the laboratory results, and radiology report. He met with Anna’s parents and spoke to them about her condition. He told them that the test results did not support admitting her to the hospital, but he stressed the need for outpatient followup care. He said that her condition was “back to baseline,” noting that her symptoms had resolved after treatment. The child’s mother was concerned that Anna was still wheezing and breathing faster than normal, but the physician ordered that she be discharged.

Nurse R noted that the child had tolerated both the albuterol and dexamethasone treatments with no adverse reaction and that her respiratory status improved. The child was discharged at 4 AM.

During the 2 hours that Anna had been in the ED, she was examined by Dr E once, a half hour after her arrival. The physician did not see her again prior to discharge.

Anna’s parents took her to her grandmother’s house after she was discharged because they had to go to work. At approximately 7 AM, the grandmother found Anna unresponsive and called 911. The child was taken by ambulance to the hospital, where she was treated for respiratory and cardiac arrest, leading to brain death. She was taken off life support 6 days later and died.