​Sepsis is dangerous, prevalent, preventable, and expensive, but because of its often subtle presentation, "if you're not looking for it, you won't see it," said Pamela L. Popp, MA, JD, DFASHRM, CPHRM, AIM, DSA, executive vice president and chief risk officer, Western Litigation, speaking September 26, 2016, at the annual conference of the American Society for Healthcare Risk Management. "Suspect sepsis, then rule it out," she advised. Emphasizing that sepsis deserves risk management attention, Popp noted that the condition can escalate quickly and is associated with high morbidity and mortality. Sepsis is also the most costly inpatient hospital condition and a leading cause of 30-day readmissions. Lawsuits can result in high damages due to high inpatient costs, need for future medical care, significant injuries or death, and life-changing postsepsis syndrome. In fact, sepsis survivors "need the kind of supportive care that a cancer patient needs . . . but such processes aren't in place and the effects [on] patients and families are significant," Popp said. In an analysis of patient safety issues in sepsis-related events from the database of ECRI Institute's patient safety organization (PSO), need for a higher level of care was the most common category, reported Josi Wergin, CPASRM, ELS, risk management analyst, ECRI Institute. But in many of these cases, "it wasn't really clear what happened with the patient's care up until the patient was transferred," making these cases good targets for further investigation and learning, she said. Delays in screening or diagnosis and delays in treatment were the second and third most common categories, respectively. "Delays spanned many areas," including patient care areas, the pharmacy, the laboratory, and communication with physicians. Wergin also shared lessons and strategies she distilled from experts. For example, many organizations that are undertaking sepsis initiatives form steering committees at the health system and facility level, which routinely review performance data and relevant literature and resources. Many also report that they know what they are supposed to do, but the challenge lies in doing those things quickly for every patient who needs them. Thus, organizations may wish to measure adherence to bundles or guidelines and then analyze and adjust the work system and processes, Wergin noted. "Make it easy for people to adhere to the guidelines, bundles, and tools," she added.