The Unfortunate Admission

This was the case study used in the National Forum Clarion Case Study Competition at IHI's 2008 National Forum on Quality Improvement in Health Care.  Students conducted a root cause analysis. 
Clarionsmall.bmpCase study from Clarion at the University of Minnesota

Learning Objectives:
After reading this case study and the associated slides, students will be able to list several "upstream" causes of error leading to the death of a fictional patient.
The Case:
Jane Nagel is an 18-year-old woman who presented to the emergency department (ED) at 5 p.m. complaining that she was “not feeling well.” She told the admitting staff she had nasal congestion, stuffiness, sore throat and a cough for the last couple weeks. She also had achy joints and chest discomfort on the right side. In fact, her cough led her to quit smoking for two weeks. She had not been drinking or eating much during the last few days, and she said her urine was darker than usual...
Reprinted with permission from Clarion at the University of Minnesota.  If you're interested in learning more or participating in the National Clarion Competition, please contact
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