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ClarionslidesMichelle_Valerie_Karen_JoEllen.ppt1st 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
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DR
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
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
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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
