Alyssa - 9 year old female - diagnosed with Acute
Lymphoblastic Leukemia

What do you think is going on with this patient?
(everyone to answer)

Initial Assessment ( ~3 min)

Admitted to hospital for bone marrow transplant.

Place in room with shared bathroom.

one week later, abdominal pain, pale, fever, headache, fatigue, lymphadenopathy, bruising

Share what you are most concerned about.
(everyone to answer)

Assessment Review ( ~3 min)

Next morning, Alyssa's father felt her foot was ice cold, called for help, immediately transferred to the intensive care unit, then into surgery.
Summary:

Alyssa died March 8, 2007 (10 days after her diagnosis of leukemia)

Alyssa contracted C.Diff (most likely contracted from the boy who died in the adjacent room and shared bathroom), became septic and had typhlitis.

Although labs showed critical values failing, team failed to act on critical lab values.
Summary:

It took 3 years, 7 months and 28 days for the hospital that treated Alyssa to have a conversation with her family about what happened. This delay of transparency and error disclosure caused additional pain and suffering for Alyssa’s family as they grieved their loss.
What can our team learn from this case to improve the care in a similar situation?
Team Discussion (~5 min)
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:
- premature closure
- early recognition of sepsis
- failure to rescue
- in-hospital transmission of C.Diff
- transparency with family
- error disclosure
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