NHS Resolution: Case story. Missed opportunities to prevent cardiac arrest and subsequent severe hypoxic brain injury in an intensive care patient (September 2017)

Summary

This case story highlights the missed opportunities that could have prevented a cardiac arrest and subsequent severe hypoxic brain injury in an intensive care patient. 

Content

Key learning points

• If the patient had been more closely observed it is likely cardio-respiratory arrest and subsequent hypoxic brain injury could have been avoided.
• Effective procedures for nurse communication, effective handover and observation of critically unwell patients in intensive care and high dependency units are very important to safe patient care.
• Bedside and remote monitoring equipment provide vital information to staff and should be properly maintained and replaced where necessary.