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- Pediatric Surgery
- Structured Hand-offs
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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 > Review
Macdonald AL, Sevdalis N. J Pediatr Surg. 2017;52:504-511.
Journal Article > Study
Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Pediatr Crit Care Med. 2011;12:309-313.
Use of a structured tool improved the quality of handoffs for postoperative pediatric cardiac surgery patients.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.