Kate - 8 year old female survived 5 battles of bilateral retinoblastoma since diagnosed at 5 months, recently developed limp and pain in right leg. Scheduled biopsy to determine if osteosarcoma.

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

Initial Assessment ( ~3 min)

Kate - 2 days post biopsy, declining, blood test shows elevated white blood cell count and early signs of kidney failure.

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

Review Assessment ( ~3 min)

Kate in OR, by parental demand, to reopen biopsy surgical site ... puss explodes out of the wound upon opening ...
Summary:

Kate died in February 2000 due to septic shock and multi organ failure.

Family states - you think hearing your child has cancer is the worst thing there could be, sepsis to us was worse.
What can our team learn from this case to improve the care in a similar situation? (everyone to answer)
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:
- surgical site infection
- recognition of sepsis
- premature closure
- care coordination with family
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