1. Quality Improvement and Patient Safety Forum
Jimmy Crumbacher
2/15/2017

2. This is a peer review document subject to the confidentiality requirement of the New Mexico Review Organization Immunity Act, NMSA § (2003). Unauthorized disclosure is strictly prohibited and subject to fines.

3. Objectives Preform a systems audit Identify system-based root causes
Propose system-level interventions
Prioritize interventions based on effort-yield projections

4. Systems Audit Review the case Identify one outcome to work on
Determine the overall cost of this outcome
Identify system-based root causes that contributed to this outcome
Pick one systems issue to address
Propose system-level interventions
Prioritize based on effort-yield projections

5. Case
53 year old woman presents to clinic with severe headache x 4 days. It woke her up from sleep and has not gone away. She has no vision changes, but her ‘vision is so bad, I can’t tell anyway’.
ROS: + Nausea and Vomiting
PMHx: Seizure disorder - thinks it is controlled and hasn’t had an episode in 10 years.
Social: + tobacco, is a caregiver for a younger woman who needs 24 hour assistance

6. Case Continued VSS Exam normal
A/P: Can’t rule out subarachnoid hemorrhage, recommended going to the ER for evaluation.
Patient states she can’t wait in an ER, ad hoc for urgent CT.

7. The Outcome CT head never scheduled
3 days later, was seen for another ACV for MSK pain, no mention of headaches

8. What were the costs or potential costs of of this adverse outcome?

9. Systems-Based Root Causes?

10. One Specific Systems Issue

11. Potential Systems-Level Interventions?

12. Effort VS. Yield
Can you prioritize these interventions based on effort versus yield?

13. Our Suggested Interventions?

14. Objectives Preform a systems audit Identify system-based root causes
Propose system-level interventions
Prioritize interventions based on effort-yield projections

15. References
Szostek, Jason H., et al. "A systems approach to morbidity and mortality conference." The American journal of medicine (2010):