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Hildy Schell-Chaple, RN, PhD; September 2019
After undergoing a scheduled percutaneous coronary intervention, a man with a femoral sheath still in place was admitted to the medical ward, where several beds had recently been converted to cardiac telemetry beds. Having limited experience with femoral sheaths, the nurse removed it but was unable to assess the patient every 15 minutes as required due to becoming busy with another patient. One hour later, the patient was unresponsive, a code was called, and he was transferred to the intensive care unit where he died several hours later.
Journal Article > Study
Wilkinson WE, Cauble LA, Patel VL. J Patient Saf. 2011;7:213-223.
This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.