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Challenges of missed and delayed diagnosis

Challenges of missed and delayed diagnosis. Is there anyone who has no experience of this either personally or through being involved subsequently or both?? A real life case story Break out groups What we can do to minimise it, deal with it and share learning. Katie. 9 months old

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Challenges of missed and delayed diagnosis

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  1. Challenges of missed and delayed diagnosis Is there anyone who has no experience of this either personally or through being involved subsequently or both?? A real life case story Break out groups What we can do to minimise it, deal with it and share learning

  2. Katie 9 months old Admitted to local hospital with 1 week history of fever, lethargy and increased work of breathing • Initial management • 02 • Antibiotics • In patient for 5 days -Increasing lethargy and vomiting • Difficult IV access – oral antibiotics • CXR unchanged • Referred to paediatric respiratory team at • tertiary centre

  3. Mum “I was so relieved at that point because I felt like I was watching her get worse every day – she’s normally such a happy little thing and all she did was lie there. By the end she didn’t even cry when they tried to take some blood from her. But everyone said she would be fine – its just a chest infection ”

  4. Transferred to tertiary centre Arrived 4 pm Saturday afternoon to paediatric ward O/A – grunting, responding to pain only. Sao02 88%, RR 50, HR 180, CRT 3 seconds Capillary blood gas – ph 6.9, BE -14, C02 8, K+ 8.4 Immediately transferred to PICU Decision to I+V VT on induction – PEA ROSC at 5 minutes Ongoing resuscitation – fluids, calcium, bicarbonate 2nd arrest – no ROSC and cannulated for ECLS after 30 minutes CPR On ECLS by 5.30 pm – 90 minutes after arrival

  5. Subsequent events Bloods – confirmed diagnosis of pneumococcal haemolytic uraemic syndrome Slow respiratory improvement Ongoing renal replacement therapy Weaned off ECLS after 5 days but remained very obtunded CT head – extensive infarction with basal ganglia changes EEG – severe encephalopathy No improvement – parents counselled re likely neurological prognosis and agreed to non escalation of care Progressive MOF – withdrawal of support

  6. What happened next? Consultant and nurse involved both went off sick No RCA Decision (that had already been considered prior to this event) to move in patient paediatric services from that site was expedited Did we learn from it? No.

  7. What about the parents? “ We let her down. We knew she was desperately sick and we kept trying to tell people but no one listened. At the end of the day I just keep thinking, there must have been something else I could have done, some way I could have got help for her. And I didn’t and we have to live with that.”

  8. Break out – your turn!!

  9. Challenges of missed and delayed diagnosis Why? The cognitive psychology How can we minimise that? – Cognitive interventions to reduce diagnostic error How do we deal with it? debriefing 2nd victim moral distress resilience We’re all in this together

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