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. For more like this, head to our podcast page. #CodaPodcast

2. Remembering Rory:
Sepsis and Learning from Error
Jo Anna Leuck, MD
@JannaLuke

3. T
R
A
G
E
D
Y

6. SCANDAL
MEDIA

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.”

13. Rory
Staunton
1994–2012

14. Was it
preventable?
Were there
clues?
Why were
they missed?

15. Why?

16. E
D
U
C
A
T
E
Sepsis recognition
Immediate care
Preventable errors

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

25. Rapid Fluid Bolus

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

30. Best Discharge Practices

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

32. Busy
Aloof
Distracted

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.

37. Rory Staunton
1994–2012