1. Sept 2, 2014 VCU INTERNAL MEDICINE MORBIDITY AND MORTALITY

2.  Discuss systems and individual issues creating barriers to delivery of patient care  Help improve patient care  Not to place blame or say who was at fault  If you were involved with this case, please do not state your involvement in the case GOALS

3.  Identify a case where there was a bad outcome, perhaps related to systems issues or cognitive error.  Review the case.  Break into groups  Small group brainstorm – why did things go wrong?  Small groups present their findings in a large group discussion.  Important to leave with root causes and possible solutions FORMAT

4. 1.Adverse event? Medical Error? Causation? 2.Did Systems Errors contribute? Which types? 3.Did Individual or Cognitive Errors contribute? Which types? 4.List Heuristic Failures leading to Individual Errors 5.What level of harm came to the patient? 6.What would you disclose? 6 STEPS TO CASE ANALYSIS

5.  Escalation  Level of care assignments KEY ISSUES

6.  6:44am  51 yo female veteran, admitted from ER with asthma exacerbation  3 wks of progressive dyspnea, worse overnight  Asthma since childhood, flares seasonally  Increased use of inhalers recently  PCP appt 8 days prior- rx medrol dose pack, did not fill, nor filled Symbicort, Singulair or loratadine (concerned about being on too many meds) HISTORY – ADMIT NOTE

7.  New yellow sputum  Denies fevers, chills, N/V/D  Denies sick contacts  Hospitalized once for asthma, no prior intubations HISTORY - ADMIT NOTE

8. PMHx  Asthma- PFTs mild obstructive dz, last exac 1 yr ago, treated with prednisone  Low back pain  headaches  anemia Meds  Albuterol  Symbicort  Flonase  Gabapentin  Loratadine  Singulair  omeprazole HISTORY- PMHX, MEDS

9. SHx: Life-long non-smoker Rare ETOH No drugs FHx: none HISTORY- SHX, FHX

10.  PE:  VS –BP 116/58, P 79, R 18, T 98.5, Sats 81% on RA, up to 94% on 4L  Gen- lying with HOB elevated. Mild respiratory distress, able to speak 7-8 words between breaths  HEENT- Anicteric, EOMI, pterygia noted bilaterally. Nasal mucosa pink without discharge. Oral mucosa moist, pharynx without exudate  CV- tachycardic, regular rhythm, no S3S4, no m/r/g  Pulmo- no accessory muscle use. Diffuse insp and exp wheezing throughout PE ON ADMISSION

11.  PE:  Abd- soft, nl BS, NTND  Ext- no edema  Neuro- AAO x 4 PE ON ADMISSION

12.  Na 138, K 4.2,Cl 107, CO2 22, BUN 15, cr 0.69  WBC 12.7, Hgb 13.3, plt 262  CXR- heart size normal, lungs clear, no effusion ADMIT LABS, STUDIES

13.  Asthma exacerbation- likely due to seasonal allergies and med non-compliance  Supp O2- 4L  Given methylpred 125mg in ER  Cont prednisone 60mg po once then 40mg po daily x 4 days  Albuterol nebs every 2hrs  Ipratropium nebs every 6hrs  Resume Symbicort, Singular and Flonase A/P

14.  9:38am  Received pt in bed, eyes closed, easily arousable.  Sats 86-88% on 4L  Accepting day team to eval pt in ER  Ordered ABG, continuous nebs  7.41/36/46/22.8  MRICU consulted in ER, accepted  Pt started on BiPAP in ER ER NURSING NOTE

15. 51 yo F, presents with asthma exacerbation with high O2 demand. No O2 requirement at home. Despite dual neb treatment, the whole pt objectively has not improved. ABG ordered this AM which shows marked hypoxia. With tachypnea and lack of air movement it was decided to consult the MICU and they have agreed to further care for this patient. DAY TEAM ATTENDING NOTE

16.  Chest CT without evidence of PE, although ground glass opacities noted, concerning for atypical infection  treated in ICU with NIV, levofloxacin for atypical infection  Weaned off O2, discharged home after 4 days HOSP COURSE

17.  Escalation  Level of care assignment KEY ISSUES

18. SMALL GROUP DISCUSSIONS Modified Root Cause Analysis

19.  http://vcuhsweb.mcvh-vcu.edu http://vcuhsweb.mcvh-vcu.edu

22. 1.Adverse event? Medical Error? Causation? 2.Did Systems Errors contribute? Which types? 3.Did Individual or Cognitive Errors contribute? Which types? 4.List Heuristic Failures leading to Individual Errors 5.What level of harm came to the patient? 6.What would you disclose? 6 STEPS TO CASE ANALYSIS

23. Adverse EventMedical Error ADVERSE EVENT VS MEDICAL ERROR Taken from www.portlandtribune.com sentinal event:flickr.com

24. An unintentional, definable injury that was the result of medical management and not a disease process. ADVERSE EVENT

25. MEDICAL ERROR sentinal event:flickr.com Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

26. 1.Adverse event? Medical Error? Causation? 2.Did Systems Errors contribute? Which types? 3.Did Individual or Cognitive Errors contribute? Which types? 4.List Heuristic Failures leading to Individual Errors 5.What level of harm came to the patient? 6.What would you disclose? 6 STEPS TO CASE ANALYSIS