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Remembering Rory:Sepsis and Learning from Error
Jo Anna Leuck, MD
@JannaLuke
T R A G E D Y
SCANDAL
MEDIA
Jim Dwyer New York Times Article – Irresponsible Journalism?
Case TimelineCase Timeline
HR 140 RR 36BP 100/60
Patient: Rory Staunton (5’9” 76 kilograms)
HR 143 RR 20T 100 BP 96/46
PED ED 21:14 21:24 24:00
HR 130 RR 22T 102
WBC 14.7Bands 53%
Vomiting/PainSkin Mottling
Sent to ED
FluidsDischarged
VitalsLab Results
“…just the common flu.”
Rory Staunton
1994–2012
Was it preventable?
Were there clues?
Why were they missed?
Why?
E DUCATE
Sepsis recognitionImmediate care
Preventable errors
How We Can Improve?Recognition Rapid Treatment
Can you recognizepediatric sepsis?
Pediatric Sepsis ScoreKnowledge Recognition Management
Abnormal vitalsPoor perfusionHigh-risk patients
Fever-Adjusted Rule
Add 10 beats/min ANDAdd 5 breaths/minute for every one degree Celsius or 1.8 degree Fahrenheit temp over 38 degrees (100.4)
Look at the Skin
How We Can Improve?
Do you know bestpractices for rapid treatment?
Recognition Rapid Treatment
Rapid Access
Rapid Fluid Bolus
WAIT
Case TimelineCase Timeline
HR 140 RR 36BP 100/60
Patient: Rory Staunton (5’9” 76 kilograms)
HR 143 RR 20T 100 BP 96/46
PED ED 21:14 21:24 24:00
HR 130 RR 22T 102
WBC 14.7Bands 53%
Vomiting/PainSkin Mottling
Sent to ED
FluidsDischarged
VitalsLab Results
Best Discharge Practices
Case TimelineCase Timeline
HR 140 RR 36BP 100/60
Patient: Rory Staunton (5’9” 76 kilograms)
HR 143 RR 20T 100 BP 96/46
PED ED 21:14 21:24 24:00
HR 130 RR 22T 102
WBC 14.7Bands 53%
Vomiting/PainSkin Mottling
Sent to ED
FluidsDischarged
VitalsLab Results
Busy
Aloof
Distracted
How We Can Improve?Knowledge Recognition Communication
Do I communicate to team?Do I communicate to patient?Am I approachable?
Why?Could that be my department?
I S B A R
Identity of Patient
Situation
Background
Assessment/Action
Response/Rationale
Do I communicate to team?Do I communicate to patient?Am I approachable?
Identify ways to improve.
Plan to do better.
Stay up to date about
sepsis.
Analyze your processes.
Rory Staunton 1994–2012
