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