1st Annual National Forum Clarion Case Competition Report Out

Megan Parker, Clare Rivers, Jason Coke,Laura Shanks

December 9, 2008

20th Annual National Forum on Quality Improvement in Health Care

Case Summary

• 18 yr old female

• History of Lupus and Bi-Polar Disorder

• Presented to ED with multiple complaints

• Admitted for flare up of Lupus

• Became progressive more ill, and symptomatic of systemic infection

• Discharged despite patient concerns

• Readmitted for sepsis shock

• Patient died from pneumonia and multi-organ failure

Errors

• Patient Perspective– Non-compliance with care plan

• Provider Perspective– Misdiagnosis as a result of poor communication, test

results, and interactions of providers– Lack of accountability

• System Perspective– Inadequate training on EHR– Culture that supports “Silo” thinking– Vague Roles and Responsibilities

Root Cause Analysis

Recommendations

Problem

• Initial misdiagnosis and misinterpretation of results

• Inadequacies in continuity of care and lack of communication

Action Plan• Improve training of

disciplines

• Early Warning Scores

• Huddles/Interdisciplinary Rounds

• SBAR

• Care Manager

Recommendations

Problem

• Poor discharge planning

• Strong organizational culture against mistakes

• Failures use of EHR system

Action Plan• Discharge Checklist

• Arrange follow-up prior to discharge

• Focus on patient education

• Define scope of practice

• Promote “blame-free” environment

• Training for users

• Improve user capabilities and ease of use

Summary

• Unnecessary death occurred in hospital– Contributing factors included:

• Poor communication between care providers• A culture of blame and fear• Systems issues that lead to inefficient care

– Recommendations were given to address these issues