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Cases & Commentaries
- Web M&M
Lina Bergman, RN, MSc, and Wendy Chaboyer, RN, PhD; February 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Journal Article > Study
Silber JH, Romano PS, Rosen AK, Wang Y, Even-Shoshan O, Volpp KG. Med Care. 2007;45:918-925.
This study examined the effectiveness of three different failure to rescue definitions in evaluating the quality of care among general surgery patients. The authors conclude that the original definition, which uses all deaths rather than specific complications or deaths, provides the best reliability and validity.