Sepsis: Delayed Diagnosis, Accelerated Harm

A 32-year-old postpartum patient* presented to her primary care provider (PCP) with worsening abdominal and flank pain, chills, nausea, and increasing fatigue. Her vital signs were notable for a temperature of 102.6°F, heart rate of 118 beats per minute, blood pressure of 96/58mmHg, and respiratory rate of 24 breaths per minute. She had been evaluated at an urgent care clinic the previous night; a urine culture had been obtained there, but antibiotics had been deferred pending culture results. 

The PCP performed a focused exam that revealed lower abdominal tenderness and right flank pain. The PCP neither reviewed the laboratory results from the urgent care visit nor ordered repeat labs. She attributed the patient’s symptoms to recent childbirth and discharged the patient with a diagnosis of possible viral illness. Several hours after the visit, the urine culture returned positive for gram-negative bacteria, but the result was not flagged as urgent. No attempt to contact the patient was documented. That evening, the patient collapsed at home and was transported to the emergency department, where she was diagnosed with septic shock, acute kidney injury, and metabolic acidosis. Despite aggressive treatment, she died within 12 hours of transport.

Sepsis is the body's extreme, dysregulated response to an infection. It is a life-threatening medical emergency and occurs when an infection triggers a chain reaction throughout the body, leading to tissue damage, organ failure, and potentially death. According to the Centers for Disease Control and Prevention (CDC), at least 1.7 million adults in the United States develop sepsis every year, and approximately 350,000 of them die during their hospitalization. 

These national statistics underscore the significance of sepsis-related harm—a pattern also evident in Coverys medical malpractice claims. An analysis of malpractice claims closed from 2021 to 2025 reveals 367 events involving a sepsis diagnosis. The top four event types for the sepsis cases reviewed are: 
 
While most sepsis-related cases occur in the inpatient setting (70%), they can also originate in the office-based setting and the emergency/urgent care department. Injuries arising from sepsis are often severe—they result in death 67% of the time.
 

Risk Recommendations 

Sepsis is a frequent driver of high-severity malpractice claims. Evidence-based treatment protocols, early detection, and standardized, timely responses are crucial for preventing patient harm. Consider the following when reviewing your organization’s sepsis program:
 

• Strengthen early recognition protocols. Sepsis is a clinical diagnosis requiring a high index of suspicion. Unlike other medical emergencies, the early signs of sepsis can be deceptively mild and attributed to benign medical conditions. Early recognition and timely intervention are crucial. Ensure that your organization’s policies, procedures, and protocols include: 
  • Screening tools. Structured, validated screening tools can improve early detection, consistency, and patient outcomes by providing objective criteria for assessment and diagnosis. They can also help mitigate cognitive bias by shifting intuitive reasoning into an analytical framework. Sepsis may present differently in the elderly and in pregnant, postpartum, and pediatric patients, so clinicians must be aware of population-specific variations and adapt screening tools accordingly. Integrate tools into clinical workflows across the entire organization, not only in the Emergency Department and Intensive Care Unit. 
  • Rapid activation systems. Consider implementing a “Code Sepsis” or “Sepsis Huddle” in which a multidisciplinary response team convenes at the bedside to expedite diagnosis and treatment following a positive sepsis screen. These rapid response protocols have been shown to increase recognition and expedite treatment. 
  • Staff education. Early recognition of sepsis symptoms can occur anywhere in the hospital, not only in critical care areas. Train all clinical staff to recognize the early signs of sepsis using a simple screening prompt. Additionally, train staff to respond appropriately when these signs are identified, including activating a sepsis escalation pathway and notifying the clinical team immediately. 
• Optimize diagnostic workups. Diagnostic lapses—including failure to order appropriate tests, delays in test ordering, and failure to reassess—are common vulnerabilities in sepsis claims. Ensure your organization follows evidence-based guidelines (e.g., Surviving Sepsis Campaign and CMS SEP-1) that outline the critical tests needed for early and accurate sepsis identification. Standardized guidelines for laboratory testing should address measuring lactate levels, drawing blood cultures, ordering repeat labs, and obtaining imaging when indicated. 
• Initiate timely treatment. Patients with suspected sepsis can deteriorate rapidly, and delays in initiating treatment can increase risk of patient harm. Evidence-based treatment guidelines/bundles can hasten treatment initiation by removing uncertainty, reducing variation between providers, and ensuring that no critical step is overlooked. Treatment guidelines should address assessment/reassessment of laboratory values, antibiotics administration, fluid resuscitation, and vasopressor administration when indicated. 
• Ensure timely follow-up on testing. Missed or delayed follow-up on test results can lead to missed or delayed diagnoses, adverse outcomes, and exposure to liability. Policies should clearly assign responsibility for follow-up on all test results—including those ordered in prior settings—especially during care transitions. Define follow-up timelines for normal, abnormal, and critical test results, and outline escalation procedures for unacknowledged results. Set expectations for communicating test results to patients and other providers. Critical results should trigger immediate, real-time communication. Require documentation of receipt, review, and action taken on every test result. Establish a tracking system that flags unacknowledged results.
• Strengthen communication. Points of care transition are particularly vulnerable to missed or failed communication. Ensure that clinicians use structured handoff tools or checklists when transferring responsibility between settings, shifts, or providers. Communicate pending results during every care transition so that the receiving provider can track receipt. Provide patients with discharge instructions written in plain language; include warning signs for returning to care and instructions for sepsis-specific warning signs.
• Evaluate your organization’s sepsis program. Claims data show that sepsis-related liability often stems from system-level breakdowns, not just individual clinical decisions. A comprehensive institutional sepsis program should include a multidisciplinary sepsis committee, a structured performance improvement initiative, a reliable system for tracking and reporting sepsis quality metrics, and dedicated support for patients during post-sepsis recovery. 

 
Sepsis remains a leading cause of preventable morbidity and mortality. Early recognition, timely intervention, and reliable system-level processes are essential to reducing harm. By implementing proactive risk management strategies, organizations can improve outcomes and decrease liability exposure.
 
*The case study presented in this article is fictional. The characters, events, and situation contained in the case study are not based on real individuals or incidents.