About a decade ago, a patient almost died when a traveling nurse mistakenly gave him a wristband indicating “do not resuscitate,” thinking it meant something else.
Event reporting is most effective if everyone knows what should be reported, there are no barriers to reporting, staff is encouraged to report, and there is proper escalation and follow-up from leadership on reported events.
A patient with acute thrombus—a blood clot in a vein or artery—was being transferred from an emergency department at a small outlying facility (“transferring facility”) to the intensive care unit (ICU) at a larger hospital (“receiving facility”).