VCU INTERNAL
MEDICINE
MORBIDITY AND MORTALITY
May 20 2014
GOALS
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
FORMAT
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
KEY ISSUES
Documentation
Review of secondary sources of information
and historical documentation
Transitions of care
Escalation of care in a DNR/DNI pt
HISTORY – ADMIT NOTE (TRANSFER)
 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”
Admission note done by intern #1 senior resident #1
HISTORY
 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- PMHX
 8/13 cath – 60% EF,
8/13 echo EF 55%
 Afib
 Anemia
 basal cell ca
 cellulitis
 CKD stage 3
 diastolic HF
 DM
 hyperlipidemia
 HTN
 MRSA leg wounds
 Obesity
 Sinusitis
 URIs
 edema
HISTORY
 Meds:
Percocet
Albuterol nebs and HFA
ASA
Atorvastatin
Ca-Vit D
Iron
Hydralazine
Lantus
ISMN
Metolazone
Warfarin
pantoprazole
 FHx – cousins with CAD,
parents deceased
 SHx – lives in SNF since
Nov 2013, no
independent ADLs, no
substance use, not
married, no kids
PE ON ADMISSION
 PE:
VS – 36.6, 145/68, 79, 12
NAD, oriented x 1
PERRL, EOMI, anicteric sclera, dry MM, goiter
Irreg irreg, no murmurs, 2+ edema
Diminished BS bilat, no wheezing, nonlabored
Abd – benign
Neuro – CN 2-12 grossly intact, follows simple
commands
Psych - cooperative
ADMIT LABS
7.51/36/199/29
Na 148, k 4.0, bicarb 34, bun 97/cr 2.2
Hgb 9, wbc 10.7, plt 264
Alb 2.4, lfts otw unremarkable
INR 2.6
Troponin 0.72 to 0.64 overnight
Ua with large leuk, pos nitrite, wbc 14, few
bacteria
A/P - ADMIT
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 CHF
Permanent A fib
CKD
HTN
Admission note done by intern #1, senior
resident #1
SPEECH PATHOLOGY NOTE DAY 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”
DAY 2 – ATTENDING NOTE
No events overnight
Mental status unchanged
Not verbal (resident note says unresponsive)
SBP 120-130, HR 80s, RR 16, tmax 37.3
No jvd, few rhonchi, irreg irreg, abd benign
Labs reviewed – new pos bcx – gpc; no
leukocytosis, hgb stable, tsh nl
Resident #2
DAY 2 RESIDENT NOTE
 A/P
Mild troponin elevation in setting of CKD and
severe HFpEF
HFpEF
Chronic AF with controlled VR
AMS with baseline cognitive decline – per cousin
he can speak and eat – with UTI, other w/u neg
so far
DMII
Speech eval noted
hypernatremia
Daily note – resident #2
HOSPITAL DAY 3
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 #4
 Resident #4 (team resident) is of f
 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 #5
Full medicine team present on rounds
Middle 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
LATER – HOSPITAL DAY #5
Cousin brings in a diary documenting
functional status over past six months –pt had
done taxes one month prior
HOSPITAL DAY #5
Discussion on rounds
Evaluation (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 #6
Seen on rounds – no change in exam
No new results
Identified need for LP
Not done that day due to coagulopathy
HOSPITAL DAY #7
EEG results called to attending
c/w encephalopathy/encephalitis
LP attempted – unsuccessful – IR called
HOSPITAL DAY 8
LP not done on day 7 - coagulopathy and IR
delay
Done on day 8
Crypto Ag 1:20, serum crypt Ag – 1:2450
Ampho and flucytosine started
ID consulted – agree with plan
Over next three days- starts responding with
tracking, verbal responses
SMALL GROUP DISCUSSIONS
Modified Root Cause Analysis
KEY ISSUES
Documentation
Review of secondary sources of information
and historical documentation
Transitions of care
Escalation of care in a DNR/DNI pt
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?