1st Annual National Forum Clarion Case Competition Report Out

Clay Ackerly MScJennifer Chi ClMS

Paige Conatser RN, BSGeri Kirkbride MSN

December 9, 2008

20th Annual National Forum on Quality Improvement in Health Care

Case Summary

• Presentation• 18 y/o female with Hx of Lupus, Bi-Polar d/o and

complicated social history, presents to the ED with chest pain and 2 week Hx of cough.

• 3 weeks prior, the pt visited the ED w/ similar complaints; Rheum f/u was recommended but pt did not f/u.

• On Admission• Admit to General Med with both a presumed Lupus

flare due to med non-adherence and a viral infx/UTI.

Case Summary

• Hospital Course• Treated with Steroids; No ATB ordered on admission. • Day 2, patient feels better but vitals begin to fall overnight.• Day 3, discharge planned.• Patient discharged despite patient verbalizing concern, poor

vitals, shortness of breath and pending blood Cxs.

• Post-Hospital• Blood Cx results back on day of discharge; pt was called to

return to hospital.• Delay in return to hospital.• Pt dies of septic shock in MICU.

Errors

• Information gaps• Incomplete history & information management issues created confusion &

delays in care.

• Omission • ATB, lab, x-rays, hand-off of pending blood culture, inpatient psych consults

not done.

• Failure to Reassess Clinical Status• Following a clinical change, pt complaints, change in vital signs, productive

cough, medication review, etc.

• Lack of standardized clinical criteria for discharge• Lack of established mechanism in the organization to support

intern getting the patient back for treatment

Root Cause Analysis

Recommendations

• Assess the culture of safety in the care environment.• Structure communication across the Health Care Team (esp. hand-

offs and after changes in the clinical assessment of the pt). • Create a system of clinical back up for trainees, and training

requirements for EMR.• Procedures for clinical oversight by RN and assignments of nursing.• Standardized discharge criteria for both clinical and social needs

based on clinical findings and social service screening. • Create a mechanism to get the pt back for treatment in a timely

manner.

Summary

Event• Unexpected death.

Root Cause • Septic shock resulting from delay of diagnosis and

treatment of pneumonia.

Contributory or Proximate Factors• In the absence of a patient safety culture, multiple

errors in communication and lapses in judgment contributed to the death of the 18 year old.