1. 20th Annual National Forum on Quality Improvement in Health Care
1st Annual National Forum Clarion Case Competition Report Out The Unfortunate Admission Michelle Johnson, Valerie Pracilio, Karen Born, Jo Ellen Holt DR
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 Process of analysis of patients’ experience:
ED visit
Admission to GM Unit
Discharge
Admission to ICU
Death
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

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
People Power
Machinery

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

6. Communication Proximate Causes Recommendations
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

7. Culture of Safety Proximate Causes Recommendations
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)

8. Equipment Proximate Causes Recommendations
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

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