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Remembering Rory:Sepsis and Learning from Error
Jo Anna Leuck, MD
@JannaLuke
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T R A G E D Y
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SCANDAL
MEDIA
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Jim Dwyer New York Times Article – Irresponsible Journalism?
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Case TimelineCase Timeline
HR 140 RR 36BP 100/60
Patient: Rory Staunton (5’9” 76 kilograms)
HR 143 RR 20T 100 BP 96/46
PED ED 21:14 21:24 24:00
HR 130 RR 22T 102
WBC 14.7Bands 53%
Vomiting/PainSkin Mottling
Sent to ED
FluidsDischarged
VitalsLab Results
“…just the common flu.”
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Rory Staunton
1994–2012
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Was it preventable?
Were there clues?
Why were they missed?
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Why?
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E DUCATE
Sepsis recognitionImmediate care
Preventable errors
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How We Can Improve?Recognition Rapid Treatment
Can you recognizepediatric sepsis?
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Pediatric Sepsis ScoreKnowledge Recognition Management
Abnormal vitalsPoor perfusionHigh-risk patients
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Fever-Adjusted Rule
Add 10 beats/min ANDAdd 5 breaths/minute for every one degree Celsius or 1.8 degree Fahrenheit temp over 38 degrees (100.4)
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Look at the Skin
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How We Can Improve?
Do you know bestpractices for rapid treatment?
Recognition Rapid Treatment
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Rapid Access
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Rapid Fluid Bolus
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WAIT
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Case TimelineCase Timeline
HR 140 RR 36BP 100/60
Patient: Rory Staunton (5’9” 76 kilograms)
HR 143 RR 20T 100 BP 96/46
PED ED 21:14 21:24 24:00
HR 130 RR 22T 102
WBC 14.7Bands 53%
Vomiting/PainSkin Mottling
Sent to ED
FluidsDischarged
VitalsLab Results
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Best Discharge Practices
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Case TimelineCase Timeline
HR 140 RR 36BP 100/60
Patient: Rory Staunton (5’9” 76 kilograms)
HR 143 RR 20T 100 BP 96/46
PED ED 21:14 21:24 24:00
HR 130 RR 22T 102
WBC 14.7Bands 53%
Vomiting/PainSkin Mottling
Sent to ED
FluidsDischarged
VitalsLab Results
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Busy
Aloof
Distracted
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How We Can Improve?Knowledge Recognition Communication
Do I communicate to team?Do I communicate to patient?Am I approachable?
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Why?Could that be my department?
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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?
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Identify ways to improve.
Plan to do better.
Stay up to date about
sepsis.
Analyze your processes.
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Rory Staunton 1994–2012
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