Case Presentation: 49 year old woman with past medical history of alcoholic cirrhosis and autoimmune hemolytic anemia treated with a course of steroids and rituximab 3 months prior who presented with 3-days of nausea, nonbloody/nonbilious vomiting and diarrhea associated with dysuria, and suprapubic discomfort. Vitals notable for heart rate 129/min, BP 115/61mmHg. Labs significant for sodium 129 (baseline 130-132), creatinine 0.8, total bilirubin 28 (baseline 19-22), white blood cells (WBC) 4.4 (baseline 9-11) with 11% bandemia, platelets 34 (baseline 50-60s), lactate of 5. Urineanalysis with 2+ leucocyte esterase and 50 WBCs. CT abdomen and pelvis showed possible cystitis, cirrhosis, and no pockets of fluid for paracentesis. Chest x-ray showed mild vascular congestion. The patient was admitted for likely viral gastroenteritis started on intravenous fluids(IVF) and stool studies were ordered. On the night of admission, the patient became febrile at 38.3. About 12 hours later, blood cultures were sent and empirically started on piperacillin-tazobactam. Patient developed recurrent hypotension despite IVF and midodrine, necessitatingpressor initiation. Repeat labs with worsening leukopenia, renal function, metabolic acidosis, and liver function tests. Blood cultures resulted positive for Escherichia coli same day. The patient had progressive septic shock with escalating pressor requirements despite stress dose steroidsand broad-spectrum antibiotics, with progression to multiorgan failure and death.

Discussion: This case has been reviewed as part of a national collaborative, Achieving Diagnostic Excellence through Prevention and Teamwork( ADEPT). Diagnostic error is thought to be highly likely with major diagnostic opportunities being 1) Anchoring bias on admission on gastrointestinal etiology despite reported dysuria, suprapubic tenderness and sepsis criteria. Team justified lactic acidosis as type B and did not weigh appropriately the documented history and exam, deeming sepsis to be unlikely 2) Failure to obtain history, unclear if patient was still on steroids 3) Anchoring bias of overnight team to day team assessment despite febrile event, not recognizing sepsis and 4) Failure to order the correct test -blood cultures on admission or during febrile event. As a result of diagnostic error leading to patient harm, our institution is intervening via the sepsis committee. CDC promotes leadership commitment, accountability, early management of sepsis, staff education, and data monitoring as core elements to improve patient outcomes (1). At our institution, we have an acute care sepsis committee which reevaluated the current sepsis best practice advisories (BPA) to improve sepsis guidelines. The modifications include categorizing the BPAs into sepsis watch, severe sepsis, and septic shock advisories, where each category includes evidence-based diagnostic and therapeutic steps. To sustain these diagnostic excellence (DE) interventions, the team tracks for compliance and challenges in sepsis protocol implementation and provides education as needed.

Conclusions: Leadership commitment and a multidisciplinary team approach are critical steps in establishing a DE team at respective institutions. The DE team would aim to engage with existing diagnosis-specific task force committees and work on improving diagnosis, treatment, and communication strategies that promote early disease pattern recognition and provide safe, effective, evidence-based, patient-centered care.