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Sept 2, 2014
VCU INTERNAL MEDICINE
MORBIDITY AND MORTALITY
Discuss systems and individual issues creating barriers to delivery of patient care
Help improve patient care
Not to place blame or say who was at fault
If you were involved with this case, please do not state your involvement in the case
GOALS
Identify a case where there was a bad outcome, perhaps related to systems issues or cognitive error.
Review the case.Break into groups
Small group brainstorm – why did things go wrong?
Small groups present their findings in a large group discussion.Important to leave with root causes and possible solutions
FORMAT
1. Adverse event? Medical Error? Causation?2. Did Systems Errors contribute? Which
types?3. Did Individual or Cognitive Errors
contribute? Which types?4. List Heuristic Failures leading to
Individual Errors5. What level of harm came to the patient? 6. What would you disclose?
6 STEPS TO CASE ANALYSIS
EscalationLevel of care assignments
KEY ISSUES
6:44am51 yo female veteran, admitted from ER with asthma exacerbation
3 wks of progressive dyspnea, worse overnight
Asthma since childhood, flares seasonallyIncreased use of inhalers recentlyPCP appt 8 days prior- rx medrol dose pack, did not fill, nor filled Symbicort, Singulair or loratadine (concerned about being on too many meds)
HISTORY – ADMIT NOTE
New yellow sputumDenies fevers, chills, N/V/DDenies sick contactsHospitalized once for asthma, no prior intubations
HISTORY - ADMIT NOTE
PMHxAsthma- PFTs mild obstructive dz, last exac 1 yr ago, treated with prednisone
Low back painheadaches anemia
MedsAlbuterol SymbicortFlonaseGabapentinLoratadineSingulairomeprazole
HISTORY- PMHX, MEDS
SHx:Life-long non-smokerRare ETOHNo drugs
FHx:none
HISTORY- SHX, FHX
PE:VS –BP 116/58, P 79, R 18, T 98.5, Sats 81% on RA, up to 94% on 4L
Gen- lying with HOB elevated. Mild respiratory distress, able to speak 7-8 words between breaths
HEENT- Anicteric, EOMI, pterygia noted bilaterally. Nasal mucosa pink without discharge. Oral mucosa moist, pharynx without exudate
CV- tachycardic, regular rhythm, no S3S4, no m/r/gPulmo- no accessory muscle use. Diffuse insp and exp wheezing throughout
PE ON ADMISSION
PE:Abd- soft, nl BS, NTNDExt- no edemaNeuro- AAO x 4
PE ON ADMISSION
Na 138, K 4.2,Cl 107, CO2 22, BUN 15, cr 0.69
WBC 12.7, Hgb 13.3, plt 262CXR- heart size normal, lungs clear, no
effusion
ADMIT LABS, STUDIES
Asthma exacerbation- likely due to seasonal allergies and med non-complianceSupp O2- 4LGiven methylpred 125mg in ERCont prednisone 60mg po once then 40mg po daily x 4 days
Albuterol nebs every 2hrsIpratropium nebs every 6hrsResume Symbicort, Singular and Flonase
A/P
9:38amReceived pt in bed, eyes closed, easily arousable.
Sats 86-88% on 4LAccepting day team to eval pt in EROrdered ABG, continuous nebs
7.41/36/46/22.8MRICU consulted in ER, acceptedPt started on BiPAP in ER
ER NURSING NOTE
51 yo F, presents with asthma exacerbation with high O2 demand. No O2 requirement at home. Despite dual
neb treatment, the whole pt objectively has not improved. ABG ordered this AM
which shows marked hypoxia. With tachypnea and lack of air movement it was decided to consult the MICU and
they have agreed to further care for this patient.
DAY TEAM ATTENDING NOTE
Chest CT without evidence of PE, although ground glass opacities noted, concerning for atypical infection
treated in ICU with NIV, levofloxacin for atypical infection
Weaned off O2, discharged home after 4 days
HOSP COURSE
Escalation Level of care assignment
KEY ISSUES
SMALL GROUP DISCUSSIONS
Modified Root Cause Analysis
1. Adverse event? Medical Error? Causation?2. Did Systems Errors contribute? Which
types?3. Did Individual or Cognitive Errors
contribute? Which types?4. List Heuristic Failures leading to
Individual Errors5. What level of harm came to the patient? 6. What would you disclose?
6 STEPS TO CASE ANALYSIS
Adverse Event Medical Error
ADVERSE EVENT VS MEDICAL ERROR
Taken from www.portlandtribune.com
sentinal event:flickr.com
An unintentional, definable injury that was the result of medical management and not a disease process.
ADVERSE EVENT
MEDICAL ERROR
sentinal event:flickr.com
Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
1. Adverse event? Medical Error? Causation?2. Did Systems Errors contribute? Which
types?3. Did Individual or Cognitive Errors
contribute? Which types?4. List Heuristic Failures leading to
Individual Errors5. What level of harm came to the patient? 6. What would you disclose?
6 STEPS TO CASE ANALYSIS
