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ClarionslidesMegan_Clare_Jason_Laura.ppt1st Annual National Forum Clarion Case Competition Report Out
Megan Parker, Clare Rivers, Jason Coke,
Laura Shanks
December 9, 2008
20th Annual National Forum on Quality Improvement in Health Care
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DR
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
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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
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Root Cause Analysis
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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
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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
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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
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