1. 20th Annual National Forum on Quality Improvement in Health Care
1st Annual National Forum Clarion Case Competition Report Out Clay Ackerly MSc Jennifer Chi ClMS Paige Conatser RN, BS Geri Kirkbride MSN DR
December 9, 2008
20th Annual National Forum on Quality Improvement in Health Care

2. 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.

3. Case Summary Hospital Course Post-Hospital
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.

4. Errors Information gaps Omission Failure to Reassess Clinical Status
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
Multidisciplinary team assess the event and determined the following errors occurred

5. Root Cause Analysis

6. 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.

7. 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.