1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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