Nile Moss - 15 yr old male
Nile is a 15 year old male with hydrocephalus, successfully treated with two prior brain surgeries.

His condition is monitored with annual MRIs.
Initial Assessment

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

Initial Assessment ( ~3 min)

Nile visits Emergency Department (ED) 2 days after his annual MRI with contrast.

Not feeling well, presenting with symptoms of fever, wet productive cough, headache, shortness of breath, and fatigue.

Nile was tested for strep (results negative). A decision was made to send him home with antibiotics to treat strep.
Review Assessment

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

Review Assessment ( ~3 min)

Nile readmitted to the ED, following day.

Nile feeling much worse with fever and difficulty breathing. He is pale, diaphoretic, listless, and chest x-ray shows pneumonia. O2 mask is on patient.
Nile's Story

Nile died April 17, 2006 (5 days after MRI)

Family reports Nile contracted MRSA (from his MRI with contrast) which lead to sepsis.
Team Discussion
What can our team learn from this case to improve the care in a similar situation?
Team Discussion (~5 min)
Systems Discussion
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)
- premature closure
- early recognition of sepsis
- in-hospital transmission of MRSA
- poor care coordination
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