May 20 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 human 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

DocumentationReview of secondary sources of

information and historical documentation

Transitions of careEscalation of care in a DNR/DNI pt

KEY ISSUES

68 yo man who presented one day prior to transfer to outside hospital from long-term care facility with AMS Per facility – several days AMS “per cousin” – several weeks No hypoglycemia, no acute illness At OSH, 130/70, 84, 16, afebrile

Glucose 70-100 Chem notable for bicarb 35, cr 2.2, bun 94 (old) NH4 100 Head CT negative for intracranial hemorrhage CE elevated troponin 0.43, pro-BNP 9000, EKG afib,

LAD, RBBB Pt transferred “for further management of ACS”

HISTORY – ADMIT NOTE (TRANSFER)

Admission note done by intern #1 senior resident #1

On arrival, pt oriented to self, nothing else, able to follow simple commands

Note full code at OSH, made DNR/DNI after discussion with senior resident on admission

Medical hx -8/13 cath – 60% EF, 8/13 echo EF 55%Afib, anemia, basal cell ca, cellulitis, CKD stage 3, diastolic HF, DM, edema, hyperlipidemia, htn, MRSA leg wounds 2012, obesity, sinusitis, URI

HISTORY

8/13 cath – 60% EF, 8/13 echo EF 55%

AfibAnemiabasal cell ca cellulitisCKD stage 3diastolic HF DM

hyperlipidemiaHTNMRSA leg woundsObesitySinusitisURIsedema

HISTORY- PMHX

Meds:PercocetAlbuterol nebs and HFAASAAtorvastatinCa-Vit DIronHydralazineLantus ISMNMetolazoneWarfarinpantoprazole

FHx – cousins with CAD, parents deceased

SHx – lives in SNF since Nov 2013, no independent ADLs, no substance use, not married, no kids

HISTORY

PE:VS – 36.6, 145/68, 79, 12NAD, oriented x 1PERRL, EOMI, anicteric sclera, dry MM, goiter Irreg irreg, no murmurs, 2+ edemaDiminished BS bilat, no wheezing, nonlaboredAbd – benignNeuro – CN 2-12 grossly intact, follows simple commands

Psych - cooperative

PE ON ADMISSION

7.51/36/199/29Na 148, k 4.0, bicarb 34, bun 97/cr 2.2Hgb 9, wbc 10.7, plt 264Alb 2.4, lfts otw unremarkableINR 2.6Troponin 0.72 to 0.64 overnightUa with large leuk, pos nitrite, wbc 14,

few bacteria

ADMIT LABS

AMS – likely secondary to UTI, evaluate for other causes – endocrine, infection, metabolic, consider MRI if not improved

Type 2 NSTEMI – secondary to demand ischemia secondary to infection

Decompensated diastolic CHFPermanent A fibCKDHTN

A/P - ADMIT

Admission note done by intern #1, senior resident #1

-“Consulted for bedside swallowing eval in setting of AMS-Current diet: NPO; team having difficulty passing NGT due to pt’s inability or unwillingness to flex neck-Pt speaking in 1-2 word utterances, inconsistently responsive, oriented to name, month, date of birth”

SPEECH PATHOLOGY NOTE DAY 1

No events overnightMental status unchangedNot verbal (resident note says

unresponsive)SBP 120-130, HR 80s, RR 16, tmax 37.3No jvd, few rhonchi, irreg irreg, abd

benignLabs reviewed – new pos bcx – gpc; no

leukocytosis, hgb stable, tsh nl

DAY 2 – ATTENDING NOTE

Resident #2

A/PMild troponin elevation in setting of CKD and severe HFpEF

HFpEFChronic AF with controlled VRAMS with baseline cognitive decline – per cousin he can speak and eat – with UTI, other w/u neg so far

DMIISpeech eval notedhypernatremia

DAY 2 RESIDENT NOTE

Daily note – resident #2

No significant change in exam or labs except urine cx positive Pseudomonas

No significant change in plans except addition of cefepime for Pseudomonas UTI and vanc for gpc in blood

Transfer to medicine

HOSPITAL DAY 3

Resident #3 (sister team - covering for admitting team) writes transfer note

Reviews details to date – no new plans or assessment

HOSPITAL DAY #3

Resident #4 (team resident) is off Intern #2 (med team intern) writes daily note Attending writes addendum

AMS - apparently pt has had increasing AMS at nursing facility for several weeks. Etiology of altered mental status is unclear - ? infection (has current UTI as noted below - just started on appropriate abx for sensitivities) vs metabolic (Na on admission elevated, BUN is chronically elevated in 70-100 range, need to check NH4) vs endocrine (note TSH nl, consider cortisol eval) vs primary CNS such as fall and SDH (note neg CT done - does have chronic changes and evidence of chronic small vessel ischemic disease) vs meds/toxins (no clear evidence of specific agent and neg UDS on admission) vs other. At this point, we are treating for infection and hypernatremia and following MS closely. He does have a cough response but needs to be monitored closely. Continue to obtain further hx from family to identify any other possible etiologies - will contact nursing facility to review list of meds again though, per extensive review of medical chart, cannot identify specific offending med at this time. Appears that baseline one year ago was living independently, since admission last summer, has been in SNF but still fairly functional.

HOSPITAL DAY #4

Full medicine team present on roundsMiddle of rounds – acute respiratory distress

Sr Resident (#4)– MRICU consulted, however cancels MRICU consult, states “comfort care only”(Impression per handoff from resident #3)

Attending disagrees after chart review night prior – sees potentially reversible causes that should be evaluated and treated – with overall time trial

HOSPITAL DAY #5

Cousin brings in a diary documenting functional status over past six months –pt had done taxes one month prior

LATER – HOSPITAL DAY #5

Discussion on roundsEvaluation (thorough) of AMS, including EEG, MRI

DNR/DNI, no escalation of care (pressors, intubation, hemodialysis, etc) – discussed with family – but aggressive evaluation with time trial of evaluation and therapy

HOSPITAL DAY #5

Seen on rounds – no change in examNo new resultsIdentified need for LPNot done that day due to coagulopathy

HOSPITAL DAY #6

EEG results called to attendingc/w encephalopathy/encephalitis

LP attempted – unsuccessful – IR called

HOSPITAL DAY #7

LP not done on day 7 - coagulopathy and IR delay

Done on day 8Crypto Ag 1:20, serum crypt Ag – 1:2450Ampho and flucytosine startedID consulted – agree with plan

Over next three days- starts responding with tracking, verbal responses

HOSPITAL DAY 8

SMALL GROUP DISCUSSIONS

Modified Root Cause Analysis

DocumentationReview of secondary sources of

information and historical documentation

Transitions of careEscalation of care in a DNR/DNI pt

KEY ISSUES

LARGE GROUP DISCUSSION

Was there a medical error in the adverse event that occurred in today’s discussion? Was that error preventable?

What were the health system forces that contributed to the error? How can those systems be changed to prevent a similar adverse event from occurring in the future?

LARGE GROUP DISCUSSION

Was there a cognitive error that contributed to the error? How would you address the cognitive error?

Please recommend one course of action that our institution can take to prevent an event like this in the future. Who else should be involved in this process? What would be the role of the residents and students?