Nurse’s Failure to Place Order for Vaccine Causes Meningitis


This case involves the failure of a nurse to follow up on a physician’s order for a post-splenectomy vaccination in a thirteen-year-old patient. The surgeon placed the order and referenced it in his postoperative plan, but the nurse failed to transition the order into the patient’s MAR (Medication Administration Record), which is the official document for releasing medications from the pharmacy by a pharmacist. The patient left the hospital without receiving the vaccine and developed meningitis and severe brain damage from the avoidable infection.

Question(s) For Expert Witness

  • 1. Why is the vaccination in post-splenectomy patients so important and should it be part of the normal discharge orders in patients that have this procedure?

Expert Witness Response E-006335

The splenectomized patient should be vaccinated to decrease the risk of overwhelming postsplenectomy sepsis, due to organisms such as Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis. Patients should be vaccinated during the hospital stay because they may have unreliable follow-up once discharged. In elective cases, vaccination two weeks before the procedure is also shown to be very beneficial. Patients should be educated prior to discharge on the risk of OPSS and their immunocompromised state. An understanding of the need for prompt medical attention should be instilled in such patients to reduce the morbidity and mortality of postsplenectomy infection.

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