20th Annual National Forum on Quality Improvement in Health Care 1st Annual National Forum Clarion Case Competition Report Out Megan Parker, Clare Rivers, Jason Coke, Laura Shanks DR 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 Unnecessary patient death Misdiagnosis Assumptions about patient condition Incomplete information Hand-off Communication Lack of interaction between providers Accountability Lack of follow-through System Deficiencies Process errors

Recommendations Action Plan Problem Improve training of disciplines Early Warning Scores Huddles/Interdisciplinary Rounds SBAR Care Manager Initial misdiagnosis and misinterpretation of results Inadequacies in continuity of care and lack of communication

Recommendations Problem Action Plan Poor discharge planning Strong organizational culture against mistakes Failures use of EHR system 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