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Challenges of missed and delayed diagnosis - PowerPoint PPT Presentation


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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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Presentation Transcript
slide1
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

slide2
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
slide3
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 ”

slide4
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

slide5
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

slide6
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.

slide7
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.”

slide9
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