This is a review of the case study Code Blue-Where To?, The patient in this case is an 80 year old patient admitted to a psychiatric facility, who ultimately dies. His death is not the fault of the medical staff, but the care he received prior to his death was plagued with system errors and communication breakdowns that could be argued as causing undue patient harm. The errors include problems with staff training, policy and procedures, outdated equipment, and failure to follow protocol. These errors are completely preventable and all too common in today’s medicine.
The patient is again an 80-year-old male with a history of schizophrenia and a medical history of coronary artery disease and hypertension. The patient was admitted to the psychiatric unit for treatment of positive symptoms of his schizophrenia. On the second day of treatment the patient lost consciousness after experiencing a sudden onset of hypotension, bradycardia, and confusion. Shortly after the patient lost …show more content…
There are several reason staff may have not been trained which could include the staff being new to the unit and not familiar with procedures or perhaps a code had never occurred on the psychiatric unit. It was obvious that the code team was also not trained on the procedure for answering a code in the psychiatric unit.
Equipment. The next system error that occurred has to do with available supplies. The psychiatric unit was using older, incompatible leads which led to a nurse having to return to the main hospital to obtain the correct leads. The other equipment issue that was present in this case was the lack of an available code cart on the psychiatric unit. This again can be argued as causing patient harm, by delaying