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Coda Change

Mar 28, 2017

Jo Anna Leuck discusses how to learn from error in paediatric sepsis.

Rory was a healthy 12-year-old boy, known for his smile and for standing up for others. A simple fall during basketball practice caused an abrasion on his arm. This is the suspected beginning of a cascade of events that led to his death from sepsis.

Rory was seen by both his paediatrician and a local Emergency Department and was sent home with a diagnosis of a viral illness.

He returned the next day in septic shock and died shortly thereafter. A review of the medical records revealed that there were errors that occurred during his emergency department visit.

This talk will attempt to move away from the controversy of the actual article and instead focus on how these common errors could have occurred during any busy shift and what we can do to prevent them in the future.

Jo Anna’s intention in giving this talk is to continue to use this case to raise awareness of both paediatric sepsis and common medical error.

When considering paediatric sepsis Jo Anna asks - Was this preventable? Were there clues? Why was this missed?

Jo Anna discusses what we can we do better.

Recognition is the first step. Often procedures are used in this case. The Paediatric Sepsis Score is one such example.

Jo Anna talks about vital signs and how they are tricky in kids due to the changing reference ranges depending on age. Jo Anna recommends having easily accessed charts and stresses thinking twice about the size and age of the child in front of you.

The physical exam is as important as always. In kids, there are certain signs that should raise suspicion such as skin mottling. And in terms of treatment Jo Anna stresses rapid access, rapid fluid boluses and thorough re-evaluation alongside age-appropriate empirical antibiotics.

Lastly, Jo Anne touches on the errors that this case highlights. She provides some strategies to improve your practice.

Before discharge consider three main components. Vital signs, diagnostic studies, and communication!

Simple, but careful attention to these components of care will lead to the medical profession learning from errors and preventing them in the future.

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