Remembering Rory: Sepsis and Learning from Error
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The document discusses the case of Rory Staunton, a young patient who suffered from sepsis, highlighting failures in its recognition and treatment. It emphasizes the importance of educating healthcare professionals on sepsis management and improving communication within medical teams to prevent similar tragedies. The document also advocates for better discharge practices and rapid treatment protocols for high-risk patients.
Remembering Rory: Sepsis and Learning from Error
- 2. Remembering Rory: Sepsis and Learning from Error Jo Anna Leuck, MD @JannaLuke
- 7. Jim Dwyer New York Times Article – Irresponsible Journalism?
- 12. Case TimelineCase Timeline HR 140 RR 36 BP 100/60 Patient: Rory Staunton (5’9” 76 kilograms) HR 143 RR 20 T 100 BP 96/46 PED ED 21:14 21:24 24:00 HR 130 RR 22 T 102 WBC 14.7 Bands 53% Vomiting/Pain Skin Mottling Sent to ED Fluids Discharged Vitals Lab Results “…just the common flu.”
- 14. Was it preventable? Were there clues? Why were they missed?
- 15. Why?
- 17. How We Can Improve? Recognition Rapid Treatment Can you recognize pediatric sepsis?
- 19. Pediatric Sepsis Score Knowledge Recognition Management Abnormal vitals Poor perfusion High-risk patients
- 21. Fever-Adjusted Rule Add 10 beats/min AND Add 5 breaths/minute for every one degree Celsius or 1.8 degree Fahrenheit temp over 38 degrees (100.4)
- 22. Look at the Skin
- 23. How We Can Improve? Do you know best practices for rapid treatment? Recognition Rapid Treatment
- 24. Rapid Access
- 28. WAIT
- 29. Case TimelineCase Timeline HR 140 RR 36 BP 100/60 Patient: Rory Staunton (5’9” 76 kilograms) HR 143 RR 20 T 100 BP 96/46 PED ED 21:14 21:24 24:00 HR 130 RR 22 T 102 WBC 14.7 Bands 53% Vomiting/Pain Skin Mottling Sent to ED Fluids Discharged Vitals Lab Results
- 31. Case TimelineCase Timeline HR 140 RR 36 BP 100/60 Patient: Rory Staunton (5’9” 76 kilograms) HR 143 RR 20 T 100 BP 96/46 PED ED 21:14 21:24 24:00 HR 130 RR 22 T 102 WBC 14.7 Bands 53% Vomiting/Pain Skin Mottling Sent to ED Fluids Discharged Vitals Lab Results
- 33. How We Can Improve? Knowledge Recognition Communication Do I communicate to team? Do I communicate to patient? Am I approachable?
- 34. Why?Could that be my department?
- 35. I S B A R Identity of Patient Situation Background Assessment/Action Response/Rationale Do I communicate to team? Do I communicate to patient? Am I approachable?
- 36. Identify ways to improve. Plan to do better. Stay up to date about sepsis. Analyze your processes.