1st Annual National Forum Clarion Case Competition Report Out

The Unfortunate Admission

Michelle Johnson, Valerie Pracilio, Karen Born, Jo Ellen Holt

December 9, 2008

20th Annual National Forum on Quality Improvement in Health Care

Case Summary

• Multiple system failures led to poor coordination of care and communication complicated by inadequate technology and a absence of a safety culture. The result was death of Jane Nagel an 18 y/o female from complications of septic shock.

Case Summary

Process of analysis of patients’ experience:• Review of care journey to identify errors, misses

and lapses in patient care processes• Following identification of these events we

analyzed proximate causes in order to identify system factors

ED visit Admission to GM Unit Discharge Admission to ICU Death Death

Fishbone Diagram

Methods Management Environment

Machinery

Failure to diagnose and treat septicemia

People Power

Hand offs and transitions

Safety culture Inadequate community linkages

No care team in place

Inadequate EMR and referral systems

No case manager

Coordination of Care

• Failure to arrange psychiatric consult

• Failure to arrange social work consult

• Failure of appropriate handoffs

• Failure of adequate discharge planning

Recommendations

• Assignment of a patient resource manager (PRM)

• Coordination between community sober house and hospital care team

• Process for arranging a timely psych consultation

• Failure to huddle (care team)

Proximate Causes

Communication

• Communication between care providers– attending and interns– pharmacy and providers– nursing and other care providers– lab and care providers

• Communication during handoffs

• Inappropriate documentation “qday”

Recommendations

• Standardized system and processes for taking patient’s history

• Standing orders for abnormal vitals

• SBAR communication between care providers

• Improve adherence to abbreviation standards

Proximate Causes

Culture of Safety

• Medical intern did not feel comfortable to disclose error when realized

• LPN was reluctant to disagree with the intern, to report error to attending

Recommendations

• Organizational survey regarding barriers to disclosure

• Educational campaign around Just Culture

• Implementation of a safety reporting system (SRS)

Proximate Causes

Equipment

• EHR does not contain patient’s complete medical hx.

• No EHR alerts to support unfulfilled med order - Plaquenil not filled

• No CPOE – Levofloxacin not ordered

• Inadequate Psych referral system

Recommendations

• More robust decision support system– point-of-care CPOE– alerts– hard stop for looking at old

labs – “new labs pending”– electronic signature

• Process in place to allow access to full patient record

Proximate Causes

Recommendations

• Assignment of a care coordinator/PRM would have aided coordination of this patient’s care in addition to care provider huddles

• Standardization of communication and SBAR• A culture that supports transparency among

care providers• More robust decision support system

Summary

• Jane Nagel’s death was preventable! • This death was the result of various system-level

breakdowns: – Coordination of care – Communication– Culture of safety – Equipment

• Recommendations address these system level factors and will result in safer, more reliable, patient-centered care