VCU INTERNAL
MEDICINE
MORBIDITY AND MORTALITY
Sept 2, 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
cognitive 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
6 STEPS TO CASE ANALYSIS
1. Adverse event? Medical Error? Causation?
2. Did Systems Errors contribute? Which types?
3. Did Individual or Cognitive Errors contribute?
Which types?
4. List Heuristic Failures leading to Individual
Errors
5. What level of harm came to the patient?
6. What would you disclose?
KEY ISSUES
Escalation
Level of care assignments
HISTORY – ADMIT NOTE
6:44am
51 yo female veteran, admitted from ER with
asthma exacerbation
3 wks of progressive dyspnea, worse overnight
Asthma since childhood, flares seasonally
Increased use of inhalers recently
PCP appt 8 days prior- rx medrol dose pack,
did not fill, nor filled Symbicort, Singulair or
loratadine (concerned about being on too
many meds)
HISTORY - ADMIT NOTE
New yellow sputum
Denies fevers, chills, N/V/D
Denies sick contacts
Hospitalized once for asthma, no prior
intubations
HISTORY- PMHX, MEDS
PMHx
 Asthma- PFTs mild
obstructive dz, last
exac 1 yr ago, treated
with prednisone
 Low back pain
 headaches
 anemia
Meds
 Albuterol
 Symbicort
 Flonase
 Gabapentin
 Loratadine
 Singulair
 omeprazole
HISTORY- SHX, FHX
SHx:
Life-long non-smoker
Rare ETOH
No drugs
FHx:
none
PE ON ADMISSION
 PE:
 VS –BP 116/58, P 79, R 18, T 98.5, Sats 81% on RA,
up to 94% on 4L
 Gen- lying with HOB elevated. Mild respiratory
distress, able to speak 7-8 words between breaths
 HEENT- Anicteric, EOMI, pterygia noted bilaterally.
Nasal mucosa pink without discharge. Oral mucosa
moist, pharynx without exudate
 CV- tachycardic, regular rhythm, no S3S4, no m/r/g
 Pulmo- no accessory muscle use. Diffuse insp and
exp wheezing throughout
PE ON ADMISSION
PE:
Abd- soft, nl BS, NTND
Ext- no edema
Neuro- AAO x 4
ADMIT LABS, STUDIES
Na 138, K 4.2,Cl 107, CO2 22, BUN 15, cr
0.69
WBC 12.7, Hgb 13.3, plt 262
CXR- heart size normal, lungs clear, no
effusion
A/P
Asthma exacerbation- likely due to seasonal
allergies and med non-compliance
Supp O2- 4L
Given methylpred 125mg in ER
Cont prednisone 60mg po once then 40mg po
daily x 4 days
Albuterol nebs every 2hrs
Ipratropium nebs every 6hrs
Resume Symbicort, Singular and Flonase
ER NURSING NOTE
9:38am
Received pt in bed, eyes closed, easily
arousable.
Sats 86-88% on 4L
Accepting day team to eval pt in ER
Ordered ABG, continuous nebs
7.41/36/46/22.8
MRICU consulted in ER, accepted
Pt started on BiPAP in ER
DAY TEAM ATTENDING NOTE
51 yo F, presents with asthma exacerbation
with high O2 demand. No O2 requirement at
home. Despite dual neb treatment, the whole pt
objectively has not improved. ABG ordered this
AM which shows marked hypoxia. With
tachypnea and lack of air movement it was
decided to consult the MICU and they have
agreed to further care for this patient.
HOSP COURSE
Chest CT without evidence of PE, although
ground glass opacities noted, concerning for
atypical infection
 treated in ICU with NIV, levofloxacin for
atypical infection
Weaned off O2, discharged home after 4 days
KEY ISSUES
Escalation
Level of care assignment
SMALL GROUP DISCUSSIONS
Modified Root Cause Analysis
http://vcuhsweb.mcvh-vcu.edu
VCUHS ADULT LEVEL OF CARE QUICK GUIDE (updated 3/27/13)
ACUTE CARE UNIT
PROGRESSIVE CARE UNIT
INTENSIVE CARE UNIT
Patients are appropriate for this level of care if they meet any of the following
clinical criteria.
Patients are appropriate for transfer to this level of care from the ICU if they meet any of
the following criteria. Patients are appropriate for admission to or transfer from Acute Care
if they meet any of the following criteria.
Patients are appropriate for this level of care if they meet any of the following
criteria.
Nursing Assessment and Intervention
Required every 4 to 8 hours (unless required by protocol)
Nursing Assessment and Intervention
Required every 2 to 4 hours
Nursing Assessment and Intervention
Required continuously up to every 2 hours
Cardiovascular
Asymptomatic bradycardia/tachycardia previously documented
Cardiovascular
New onset asymptomatic bradycardia/tachycardia and is responding to treatment
Cardiovascular
Unstable bradycardia/tachycardia and is refractory to therapy
Hypotension: Stable and controlled BP with no new onset (Consider
stable chronic conditions e.g. cirrhotic patient)
Systolic BP greater than or equal to 90 or within 20% of patient's normal baseline with
hemodynamic stability or Systolic BP less than 200 or within 20% of baseline (consider
pending lab values, Hgb, lactate, fluid volume status)
Systolic BP less than 90 or within 20% of baseline with hemodynamic instability
for greater than 2 hours despite interventions and is refractory to therapy
(low Hgb, rising lactate, high need for continued fluid volume replacement)
Hypertension: Well Documented history of hypertension current BP within 25%
of patient's baseline. PRN Medications no more frequently than every 4 hours
New onset hypertension, asymptomatic requiring intermittent IV PRN or scheduled
meds for control. Interventions no more frequently than every 4 hours.
Symptomatic hypertension refractory to therapy (with altered mental status,
headache, CHF, ischemia) requiring continuous IV infusions for control
Low suspicion of Acute coronary syndrome: Check CK, CK-Mb and
Troponin (TN) at 0hrs and 2hrs
Asymptomatic with initial and subsequent Tn (-) may stay on acute care
Asymptomatic with initial Tn(+) and 2nd Tn(+) but trending down: Consider
telemetry + routine cardiology consult
Anything else, urgent cardiology consult and likely upgrade in level of care
(Consults may still be pending or not be required for ED disposition to an
inpatient unit)
Recent and/or ongoing MI with stable symptoms :
Initial Tn(-), 2nd Tn/CK-MB (+)
Initial Tn(+), asymptomatic, 2nd Tn/CK/MB(+) and upward trending
In both above cases urgent cardiology consult to help direct possible increased
level of care and management (Consults may still be pending or not be required
for ED disposition to an inpatient unit)
Ongoing/Prolonged recent symptoms c/w Acute Coronary syndrome with h/o
CAD or Tn (+) markers;. Hemodynamic instability; or unstable rhythms (CICU
consult required if not already following) (Consults may still be pending or
not be required for ED disposition to an inpatient unit)
Neurology
Neurology
Neurology
Stable - No evolving process with assessment/intervention no more frequently
than every 4 hours
Stable - No evolving process or new onset with assessment/intervention no more
frequently than every 2 hours
Unstable, new onset process with assessment/interventions more frequently
than every 2 hours
Confusion/Agitation/Substance withdrawal with RN assessment/intervention
no more frequently than every 4 hours
Confusion/Agitation/Substance withdrawal with RN assessment/intervention no
more frequently than every 2 hours
Confusion/Agitation/Substance withdrawal with RN assessment/intervention
more frequently than every 2 hours
Respiratory
Maintenance nebs, respiratory stability
Respiratory
Continuous nebulizer treatments, Nasotracheal suctioning with respiratory stability
and stable work of breathing
Respiratory
Nasotracheal suctioning with hemodynamic or respiratory instability
Initiation of nocturnal non-invasive ventilation for chronic respiratory failure
(Pulmonary consult required). For initiation of non-invasive ventilation
for acute respiratory failure while ICU bed secured
(See Non-Invasive Ventilation Guidelines)
New requirement for Non-Invasive Ventilator Initiation (BiPap)
(see Non-Invasive Ventilation Guidelines)
Respiratory stability and/or stable at baseline
Continued or progressive respiratory instability or work of breathing +/- marked
increase for Fi02 for greater than 2 hours despite intervention (Consider effect
of advanced directives, chest x-ray, ABG, treatment in decision making)
Respiratory instability, high 02 requirement not responding to treatments
Prophylactic continuous pulse oximetry
Continuous pulse oximetry / Capnography
Continuous pulse oximetry / Capnography for acute deterioration
Established, stable tracheostomies
New stable tracheostomies
New stable tracheostomies requiring additional assessment/interventions
Continuous Drug Infusions
That do not require frequent monitoring unless infusion protocol applies
Continuous Drug Infusions
amiodarone (Cordarone)
Continuous Drug Infusions
Drugs titrated for hemodynamic instability
Established CPAP/BiPap with sleep (day or night) for chronic respiratory
failure/obstructive sleep apnea (incl. pt with confirmed diagnosis and settings
per sleep study without current home equipment). Initiation of CPAP/BiPap
for patient suspected of obstructive sleep apnea (Pulmonary consult required)
(Consults may still be pending or not be required for
ED disposition to an inpatient unit)
diltiazem (Cardiazem)
dobutamine (Dobutrex): Non-titrating max dose 5 mcg/kg/min
NOTE: doses > 5 mcg/kg/min (goes to Heart Center only)
Insulin
nesiritide (Natrecor)
6 STEPS TO CASE ANALYSIS
1. Adverse event? Medical Error? Causation?
2. Did Systems Errors contribute? Which types?
3. Did Individual or Cognitive Errors contribute?
Which types?
4. List Heuristic Failures leading to Individual
Errors
5. What level of harm came to the patient?
6. What would you disclose?
ADVERSE EVENT VS MEDICAL ERROR
Adverse Event
Medical Error
sentinal event:flickr.com
Taken from www.portlandtribune.com
ADVERSE EVENT
An unintentional,
definable injury that
was the result of
medical management
and not a disease
process.
MEDICAL ERROR
Failure of a planned
action to be
completed as
intended or the use
of a wrong plan to
achieve an aim
sentinal event:flickr.com
6 STEPS TO CASE ANALYSIS
1. Adverse event? Medical Error? Causation?
2. Did Systems Errors contribute? Which types?
3. Did Individual or Cognitive Errors contribute?
Which types?
4. List Heuristic Failures leading to Individual
Errors
5. What level of harm came to the patient?
6. What would you disclose?