1. 1 st Annual National Forum Clarion Case Competition Report Out Megan Parker, Clare Rivers, Jason Coke, Laura Shanks December 9, 2008 20 th 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 Problem Initial misdiagnosis and misinterpretation of results Inadequacies in continuity of care and lack of communication Action Plan Improve training of disciplines Early Warning Scores Huddles/Interdisciplinary Rounds SBAR Care Manager

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