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Cases & Commentaries
- Web M&M
Donna L. Washington, MD, MPH; January 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.
Journal Article > Study
Detection of missed injuries in a pediatric trauma center with the addition of acute care pediatric nurse practitioners.
Resler J, Hackworth J, Mayo E, Rouse TM. J Trauma Nurs. 2014;21:272-275.
Missed injuries and delayed diagnoses are a relatively common problem in trauma care. This study describes a 150% increase in the number of documented missed injuries that were caught following the introduction of acute care nurse practitioners on a pediatric trauma service. The authors attribute the uptick in identified missed injuries to better charting and follow-up examinations.