Category archives for Failure To Rescue

NURSE INTUBATES PATIENT AND IS BARRED FROM HOSPITAL….WHAT IF???

Around the year 2008 an agency nurse intubated a patient that was obtunded, had decreased respirations, and decreased oxygen saturation and was ultimately barred from the hospital….What If…that nurse had not performed the intubation and the patient had coded and died. The setting is a level one teaching hospital ICU that has a residency/fellowship program.  […]

RESUSCITATION OF THE CARDIAC SURGICAL PATIENT

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Cardiac surgery patients are different from many other patients for a number of reasons when it comes to resuscitation post arrest. arterial line, Swan-ganz catheter (generally), and cardiac monitor; thus allowing for very early defibrillation without the use of external cardiac massage (ECM). ECM should be avoided if at all possible due to risk of […]

Changes needed to improve in-hospital cardiac arrest care, survival

The American Heart Association put out a statement in March of this year (2013) stating that improvements needed to be made in the way hospitals deal with in-hospital cardiac arrests.  Two main points were made: Improvements in the readiness of hospitals and the health care providers in giving evidence based quality care during cardiac arrests, […]

ICU MONITORS: IMPROPER SETTINGS/MUTED

Untreated respiratory arrest and DEATH.  Patient found asystolic with resulting DEATH.    ST elevation goes unnoticed in a post anterior MI patient that had received a LAD stent.  The patient infarcts, goes into v-fib and is unable to be resuscitated.  These are all examples of what happens when monitor alarms are turned off, muted, or […]

WHEN SIMPLE PROCEDURES GO WRONG

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“It’s Before Code Blue” Failure to rescue is when caregivers do not pick up on the subtle changes that precede the “Code Blue”.  Fresh post-op patients and patients receiving pain medications are at highest risk for failure to rescue or for subtle changes to be missed.  The post-op patient has the added benefit of also […]