Rory - 12 yr old healthy male - Scrapes his elbow playing basketball in the school gym (Day 1)
Initial Assessment
What do you think is going on with this patient?
(everyone to answer)
Initial Assessment ( ~3 min)
Day 2, Rory is at doctor's office presenting with symptoms of fever (104), pain in leg, stomach tenderness, and mottled skin.
Doctor suspects Rory has a stomach virus (that has been going around), and sends him to the ED to get rehydrated.
Review Assessment
Share what you are most concerned about.
(everyone to answer)
Review Assessment ( ~3 min)
Day 2 evening, Rory in the ED for rehydration, blood was drawn for labwork, 2 bags of fluid were administered, vital signs were worsening.
Bloodwork comes back 1 hour later showing abnormalities indicating Rory was seriously ill. Lab report was not reviewed and Rory was sent home with anti-nausea medication.
Nose black
ER
Share what you are most concerned about.
(everyone to answer)
Review Assessment (~5 min)
Day 3, Rory continued to complain of pain, his skin was jaundice, tip of his nose turned black, listless, diaphoretic, and fever. Rory readmitted to the ED, then transferred to the ICU.
Rory's Story
Summary:
Rory died April 1, 2012 (5 days after scrape)
Rory died from streptococcal sepsis.
Team Discussion
What can our team learn from this case to improve the care in a similar situation?
What systems do we have in place to prevent this? (every team member to answer)
What system issues might have contributed to this outcome? (every team member to answer)
Systems Discussion (~5 min)
Issues: - failure to clean injury - premature closure - failure to timely review lab values - no attempt to follow up with family concerning lab values - recognition of sepsis
