December 9, 2008 20 th Annual National Forum on Quality Improvement in Health Care

1. 1st Annual National Forum Clarion Case Competition Report OutThe Unfortunate AdmissionMichelle Johnson, Valerie Pracilio, Karen Born, Jo Ellen Holt December 9, 2008 20th Annual National Forum on Quality Improvement in Health Care

2. 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.

3. Case Summary ED visit 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 Admission to GM Unit Discharge Admission to ICU Death

4. Fishbone Diagram Methods Management Environment Hand offs and transitions Safety culture Inadequate community linkages No case manager Failure to diagnose and treat septicemia No care team in place Inadequate EMR and referral systems Machinery People Power

5. Coordination of Care Proximate Causes 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) • Failure to arrange psychiatric consult • Failure to arrange social work consult • Failure of appropriate handoffs • Failure of adequate discharge planning

6. 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” Standardized system and processes for taking patient’s history Standing orders for abnormal vitals SBAR communication between care providers Improve adherence to abbreviation standards Communication Proximate Causes Recommendations

7. Medical intern did not feel comfortable to disclose error when realized LPN was reluctant to disagree with the intern, to report error to attending Organizational survey regarding barriers to disclosure Educational campaign around Just Culture Implementation of a safety reporting system (SRS) Culture of Safety Proximate Causes Recommendations

8. 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 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 Equipment Proximate Causes Recommendations

9. 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

10. 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