Abstract Recurrent cerebrovascular accidents (CVAs) shortly after hospital discharge are sentinel events that warrant careful systems-based evaluation. The Systems Engineering Initiative for Patient Safety (SEIPS) framework provides a structured approach to identify latent errors in care delivery processes. Patients with malignancy and autoimmune disorders, such as recurrent metastatic follicular thyroid cancer and antiphospholipid syndrome (APS), are at increased thrombotic risk. Lenvatinib, a multikinase inhibitor targeting VEGF receptors, further increases the risk of thrombotic events through erythropoietin-mediated hematocrit elevation. Timely discontinuation of prothrombotic medications and initiation of antiplatelet or anticoagulation therapy are crucial to prevent recurrent CVA.A 69-year-old female with metastatic follicular thyroid cancer presented with nausea, confusion, and fatigue. Lenvatinib had been discontinued two days prior due to palmar-plantar erythrodysesthesia. On examination, she was hypertensive with left-sided gaze palsy, left upper extremity weakness, and left lower extremity weakness. CT head revealed right subcortical hypodensity consistent with prior CVA; MRI demonstrated scattered foci of acute ischemia bilaterally without hemorrhage. She was treated with aspirin and discharged with plans for outpatient APS serology. The following day, she was readmitted with acute aphasia. Repeat MRI showed a moderate acute infarct in the left parietal lobe, small left occipital infarcts, and evolving subacute ischemia in the right MCA territory. Prior anticardiolipin antibody results returned positive, confirming APS. Anticoagulation with warfarin was initiated.Traditional quality models, including Donabedian, Reason, and Vincent frameworks, may inadequately capture latent system errors such as pending lab results or gaps in clinical suspicion. SEIPS, by contrast, contextualizes these events within the care process, acknowledging that delays may result from system workflows rather than individual blame. In this case, delayed recognition of APS contributed to recurrent CVA. Additional latent errors included lack of consideration for citicoline, which has demonstrated efficacy in secondary stroke prevention with a lower bleeding risk (CASISP and CSPS trials). Applying SEIPS highlights opportunities for process improvement, including structured follow-up on pending lab results, integration of thrombotic risk assessment in oncology care, and early initiation of anticoagulation when indicated. This systems-based approach enables high-value patient care while minimizing recurrent adverse events and supports institutional learning from near-miss or sentinel events. This abstract is funded by: None
Thota et al. (Fri,) studied this question.