1. Quality Improvement and Patient Safety Forum

2. This is a peer review document subject to the confidentiality requirement of the New Mexico Review Organization Immunity Act, NMSA §1978 41-9-5 (2003). Unauthorized disclosure is strictly prohibited and subject to fines.

3. Objectives Preform a systems audit Identify system-based root causes Propose system-level interventions Prioritize interventions based on effort-yield projections

4. Systems Audit Review the case Identify one outcome to work on Determine the overall cost of this outcome Identify system-based root causes that contributed to this outcome Pick one systems issue to address Propose system-level interventions Prioritize based on effort-yield projections

5. Case Mom SJ is a 30 yo G1P0 who received care at an outside clinic - 22 wks bilateral pyelectasis R. renal pelvis 6.9mm L. renal pelvis 8.6mm. L. upper pole cyst 1.47X1.5X1.45cm Bladder WNL. - Recommendations - Follow up in 4 weeks reevaluation

6. Case Mom 25.3 weeks repeat US  L. renal grade 2-3 hydronephrosis with moderate hydroureter  R. grade 1 hydronephrosis no hydroureter  Suspect incomplete obstruction possible posterior urethral valves  Contact MCH provider to deliver at UNM

7. Case Mom 27.6 weeks saw MCH provider Anticipate UNM delivery unless renal concerns resolve UNM Genetic US ordered Plan q 4 week US and weekly AFI after 32-34 weeks UNM Peds nephrology consult ordered and records faxed 29.3 weeks Repeat US L. renal pelvis measures 15.8mm R. renal pelvis 11.5mm. No cystic kidney disease. Bladder has keyhole appearance Bilateral enlarged ureters

8. Pediatric Nephrology - Because of keyhole bladder and hydroureteronephrosis PUV likely -Normal AFI renal function is present. “I am relieved to see good amniotic fluid and do not expect acute renal failure at birth if urine production and amniotic fluid remain good.” Rec: Following delivery a renal ultrasound on the second day of life and VCUG follow RUS if hydronephrosis remains present. Creatinine and nephrology consult on DOL 2 or sooner if urine output is low. No nephrotoxic agents Possible surgery if PUV

9. Case Mom Q 4 week US cont to show hydronephrosis At 32.6 weeks AFI 27.93 (great working kidneys). At 36 wks AFI 19.94 As of 36.6wks plan was NSVD d/t no worsening obstruction or oligo. 36.6 wks US shows inc hydroureter, hydronephrosis, and bladder distention

10. Case MOM Admitted for IOL at 37.1 - 4/3 beautiful delivery

11. Case Baby 24 hours postpartum unclear if pt voided -Renal US ordered:  Severe bilateral hydroureteronephrosis with tortuous dilatation of the ureters down to the level of the bladder.  Cystic renal dysplasia of the right superior pole  The urinary bladder was distended, but there is no sonographic evidence of posterior urethral valves (no evidence of a dilated posterior urethra). Creatinine: 0.66 Nursing noted a large volume void after ultrasound.

12. Case Baby Pediatric Nephrologist concern  Recommended CBC with differential, CRP, Chem10, urinalysis with culture.  It was recommended that a foley not be placed, but instead strict I&Os be monitored but if no urine then contact urology to place foley. STAT orders were placed at approximately 2000 on 4/4 for labs noted above.

13. Case Baby Several attempts made to catheterize the baby was unsuccessful. Resident was paged but the page was not returned Labs collected at approximately 0400, demonstrating  NA+ 150, K+6.5  Elevated creatinine at 1.06 (was 0.66)  HCO3 18, anion gap 16 Day team contacted Pediatric Nephrologist  Care transferred to higher level for management and monitoring of kidney function  NICU was then consulted for transfer of care.

14. Possible Outcomes Delay in Diagnosis and transfer of care  Labs ordered at 8pm on 4/5  Drawn at 4am on 4/6  Called Pediatric Nephrology between 6-7am on 4/6  Transferred around 8am on 4/6

15. What were the costs or potential costs of this adverse outcome? (Do this as a group)

16. Systems-Based Root Causes? (Fishbone Diagram) Head of fishbone: Delay in Diagnosis

17. One specific systems issue

18. Potential Systems-Level Interventions?

19. Effort VS. Yield Can you prioritize these interventions based on effort versus yield?

20. Questions?

21. Objectives To preform a systems audit Second Objective

22. References Szostek, Jason H., et al. "A systems approach to morbidity and mortality conference." The American journal of medicine 123.7 (2010): 663-668.