RT Book, Section
A1 Wachter, Robert M.
A1 Gupta, Kiran
SR Print(0)
ID 1146175706
T1 Teamwork and Communication Errors
T2 Understanding Patient Safety, 3e
YR 2017
FD 2017
PB McGraw-Hill Education
PP New York, NY
SN 9781259860249
LK accessmedicine.mhmedical.com/content.aspx?aid=1146175706
RD 2024/04/20
AB A  “Code  Blue”  is  called  when  a  hospitalized  patient  is  discovered  pulseless  and  not  breathing.  The  code  team  rushes  in  and  begins  CPR.  “Does  anybody  know  this  patient?”  the  code  leader  barks  as  the  team  continues  its  resuscitative  efforts.  A  few  moments  later,  a  resident  skids  into  the  room,  having  pulled  the  patient's  paper  chart  from  the  rack  in  the  nurse's  station.  “This  patient  is  a  No  Code!”  he  blurts,  and  all  activity  stops.As  the  Code  Blue  team  members  collect  their  paraphernalia,  the  patient's  young  nurse  wonders  in  silence.  She  received  signout  on  this  patient  only  a  couple  of  hours  ago,  and  was  told  that  the  patient  was  a  “full  code.”  She  thinks  briefly  about  questioning  the  physician,  but  reconsiders.  One  of  the  doctors  must  have  changed  the  patient's  code  status  to  do  not  resuscitate  (DNR)  in  the  interim  and  forgotten  to  tell  me,  she  decides.  Happens  all  the  time.  So  she  keeps  her  concerns  to  herself.Only  later,  after  someone  picks  up  the  chart  that  the  resident  brought  into  the  room,  does  it  become  clear  that  he  had  inadvertently  pulled  the  wrong  chart  from  the  chart  rack.  The  young  nurse's  suspicions  were  correct—the  patient  was  a  full  code!  A  second  Code  Blue  was  called,  but  the  patient  could  not  be  resuscitated.1