Below is a brief description of the Team Engagement Cases:


  • Nile Moss: 15-year-old male with Hydrocephalus, successful surgeries and monitoring contracted sepsis secondary to MRSA [premature closure, delay in recognition of sepsis, in-hospital transmission of MRSA, poor care coordination]
  • Rory Staunton: 12-year-old healthy male scrapes elbow playing basketball in school gym and 5 days later died from streptococcal sepsis. [treatment at gym, premature closure, delay in review of lab values, delay in recognition of sepsis]
  • Kate Hallisy: 8-year-old female bilateral retinoblastoma survivor, develops limp an pain in right leg – biopsy to r/o osteosarcoma, post biopsy infection- delay in diagnosis – died secondary 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.” [post-op infection, delay in recognition of sepsis, premature closure, care coordination with family]
  • Sam Morrish: 3-year-old boy misdiagnosed with Flu [delay in recognition of sepsis, premature closure/confirmation bias, patient care coordination, handoff communication, care transitions delay in treatment due to poor outpatient triage, delay in antibiotic administration]

Medication Errors

  • John LaChance: middle-aged adult male, second rotator cuff repair surgery, hx. of adverse reactions to pain medications and sleep apnea died due to respiratory failure secondary to over sedation with sleep apnea [over sedation, patient centered care, engage family in care, monitoring?]
  • Leah Coufal: 11-year-old female post op pectus carinaturm corrective surgery, challenges with pain management, family expresses concern over medication, died 2 days after her surgery secondary to sedation. [failure to challenge Ativan dose, epidural placed in intrapleural space, not monitored, new EHR system and her chart not readily accessible]
  • Lewis Blackman: 15-year-old male post op pectus exacuvatum, abdomen pain, Toradol, monitor cut off to allow Lewis to sleep, died 5 days after elective surgery secondary to GI bleed because of perforated ulcer from Toradol [failure to recognize declining patient, premature closure]

Healthcare Associated Infections (HAIs)

  • Nora Bostrom: 3-year-old female diagnosed with pulmonary hypertension, on oxygen 24/7 on oral vasodilators, needed IV vasodilators, central line inserted, allergy to dressing change materials, protocol adapted, several central line infections, multiple preventable harm errors. Died secondary to preventable healthcare errors. [infection control, central line insertion and care protocols]
  • Bill Aydt: 60-year-old male status post lung transplant for idiopathic pulmonary fibrosis, falls when trying to return from bathroom, hits head, placed in traction, on bed rest – pneumonia and clostridium difficile, deep vein thrombosis, pulmonary emboli, MRSA, stage 4 bedsore, team coordination and family communication [fall prevention, respiratory complication secondary to immobility, patient assessment, patient centered care]
  • Alyssa Hemmelgarn: 9-year-old female diagnosed with acute lymphoblastic leukemia admitted for bone marrow transplant, shared bathroom with patient who died of C. Diff, died of sepsis [lack of transparency and error disclosure, premature closure]
  • Alicia Cole: middle age adult female admitted for surgery to remove two uterine fibroids [post op infection, lack of surgical asepsis in dressing change, 10-year protracted recovery from sepsis, pseudomonas, MRSA, VRE, and necrotizing fasciitis [standards of post-op care]

Care Teams

  • Donna Penner: 44-year-old having heavy menstrual bleeding and abdominal pain of unknown origin – scheduled for exploratory surgery, becomes conscious during surgery while paralyzed, feeling every incision and movement [patient monitoring, staff distraction, patient advocacy]
  • Gwen Cox: early career nurse working in coronary care unit caring for 68-year-old female patient stable with large myocardial infarction, preparing anti-hypertension while talking – double dosed patient, activated Rapid Response Team – patient recovers. Gwen become patient safety advocate with a focus on safe medication administration initiatives [safe medication administration practices, impact of distractions]
  • Annie: nurse taking care of diabetic patient, patient reports feeling like her blood sugar is high, glucometer confirms what Annie expects to see “Critical Value; Repeat; Lab draw for >600” Insulin administered, patient becomes diaphoretic and unresponsive. Rapid Response Team called; patient transferred to ICU for hypoglycemia. Annie disciplined for wrong treatment, treated with a blaming culture. similar event by another nurse. Human factors consulted to review case [Absence of Just Culture, lab response time, equipment failure]
  • Karen: experienced nurse, new hire caring for a patient who is deteriorating [patient advocacy, speaking up, and team communication]