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DNR in the OR and Afterwards
Lo B. AHRQ WebM&M [serial online]. September 2006.
An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored.
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Commentary
Setting of Care
Operating Room
Target Audience
Physicians
Nurses
Quality and Safety Professionals
Clinical Area
Anesthesiology
Surgery
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Error Types
Active Errors
Latent Errors
Approach to Improving Safety
Structured Hand-offs
Informed Consent
Checklists
Residents and Fellows
Electronic Health Records