December 9 2008 20 th annual national forum on quality improvement in health care
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1 st Annual National Forum Clarion Case Competition Report Out The Unfortunate Admission Michelle Johnson, Valerie Pracilio, Karen Born, Jo Ellen Holt. December 9, 2008 20 th Annual National Forum on Quality Improvement in Health Care. Case Summary.

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December 9, 2008 20 th Annual National Forum on Quality Improvement in Health Care

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1st Annual National Forum Clarion Case Competition Report OutThe Unfortunate AdmissionMichelle Johnson, Valerie Pracilio, Karen Born, Jo Ellen Holt

December 9, 2008

20th Annual National Forum on Quality Improvement in Health Care

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

ED visit

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

Admission to GM Unit


Admission to ICU


Fishbone Diagram




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

Coordination of Care

Proximate Causes


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)

  • Failure to arrange psychiatric consult

  • Failure to arrange social work consult

  • Failure of appropriate handoffs

  • Failure of adequate discharge planning

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


Proximate Causes


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)

Culture of Safety

Proximate Causes


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


hard stop for looking at old labs – “new labs pending”

electronic signature

Process in place to allow access to full patient record


Proximate Causes



  • 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


  • 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

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