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.
NHS Resolution: Case story. Missed opportunities to prevent cardiac arrest and subsequent severe hypoxic brain injury in an intensive care patient (September 2017)
https://resolution.nhs.uk/wp-content/uploads/2018/09/Case-story-avoidable-cardiac-arrest-and-severe-hypoxic-brain-injury.pdf
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