Remembering Rory: Sepsis and Learning from Error

Remembering Rory:Sepsis and Learning from Error

Jo Anna Leuck, MD

@JannaLuke

T R A G E D Y

SCANDAL

MEDIA

Jim Dwyer New York Times Article – Irresponsible Journalism?

Case TimelineCase Timeline

HR 140 RR 36BP 100/60

Patient: Rory Staunton (5’9” 76 kilograms)

HR 143 RR 20T 100 BP 96/46

PED ED 21:14 21:24 24:00

HR 130 RR 22T 102

WBC 14.7Bands 53%

Vomiting/PainSkin Mottling

Sent to ED

FluidsDischarged

VitalsLab Results

“…just the common flu.”

Rory Staunton

1994–2012

Was it preventable?

Were there clues?

Why were they missed?

Why?

E DUCATE

Sepsis recognitionImmediate care

Preventable errors

How We Can Improve?Recognition Rapid Treatment

Can you recognizepediatric sepsis?

Pediatric Sepsis ScoreKnowledge Recognition Management

Abnormal vitalsPoor perfusionHigh-risk patients

Fever-Adjusted Rule

Add 10 beats/min ANDAdd 5 breaths/minute for every one degree Celsius or 1.8 degree Fahrenheit temp over 38 degrees (100.4)

Look at the Skin

How We Can Improve?

Do you know bestpractices for rapid treatment?

Recognition Rapid Treatment

Rapid Access

Rapid Fluid Bolus

WAIT

Case TimelineCase Timeline

HR 140 RR 36BP 100/60

Patient: Rory Staunton (5’9” 76 kilograms)

HR 143 RR 20T 100 BP 96/46

PED ED 21:14 21:24 24:00

HR 130 RR 22T 102

WBC 14.7Bands 53%

Vomiting/PainSkin Mottling

Sent to ED

FluidsDischarged

VitalsLab Results

Best Discharge Practices

Case TimelineCase Timeline

HR 140 RR 36BP 100/60

Patient: Rory Staunton (5’9” 76 kilograms)

HR 143 RR 20T 100 BP 96/46

PED ED 21:14 21:24 24:00

HR 130 RR 22T 102

WBC 14.7Bands 53%

Vomiting/PainSkin Mottling

Sent to ED

FluidsDischarged

VitalsLab Results

Busy

Aloof

Distracted

How We Can Improve?Knowledge Recognition Communication

Do I communicate to team?Do I communicate to patient?Am I approachable?

Why?Could that be my department?

I S B A R

Identity of Patient

Situation

Background

Assessment/Action

Response/Rationale

Do I communicate to team?Do I communicate to patient?Am I approachable?

Identify ways to improve.

Plan to do better.

Stay up to date about

sepsis.

Analyze your processes.

Rory Staunton 1994–2012