“In April 2008, a 70 year old, independent lady with no previous comorbidities. became a grandmother for the first time and was looking forward to watching her family grow up. She developed a cough & became breathless and presented to her local hospital. She was admitted, and developed severe sepsis & septic shock secondary to her community acquired pneumonia and died within 7 hours. Her sepsis was not recognised, and antibiotics & fluids were not given in a timely manner. The patient’s family and the well-meaning and competent medical and nursing team were devastated.”
So begins the account of a real patient story that compelled Dr Matt Inada-Kim and colleagues to tackle the problem of managing sepsis within their practice.
The film that follows captures some aspects of the work they have done to address the problem using a human factors approach and connects strongly with Julie’s Story featured elsewhere on this site.