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Debrief Checklist - Event

A patient experienced respiratory distress and dizziness while transferring from their wheelchair to the toilet. An RRT was activated and the patient was transferred back to bed, where their vital signs were checked. The patient became combative and unresponsive, so a code blue was called. CPR and multiple doses of adrenaline were administered through various routes, but the patient did not respond and was declared dead over an hour later. The debrief checklist identified that communication and roles during the code were clear, but noted equipment for difficult IV access should be more readily available to prevent delays in future similar scenarios.

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121 views2 pages

Debrief Checklist - Event

A patient experienced respiratory distress and dizziness while transferring from their wheelchair to the toilet. An RRT was activated and the patient was transferred back to bed, where their vital signs were checked. The patient became combative and unresponsive, so a code blue was called. CPR and multiple doses of adrenaline were administered through various routes, but the patient did not respond and was declared dead over an hour later. The debrief checklist identified that communication and roles during the code were clear, but noted equipment for difficult IV access should be more readily available to prevent delays in future similar scenarios.

Uploaded by

laarni.tambiloc15
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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DEBRIEF CHECKLIST

Date and Time of Event: December 2, 2021 at 1504H


Name of Event: RRT/Code Blue
HC#: HC00398398
Brief Summary of the Event:
At 1500H, Patient called the Nurses' station and asked to go to toilet. While patient is
transferring from wheelchair ro toilet bowl, patient suddenly felt dizziness and
respiratory discomfort. At 1504H RRT activated. Assisted by one staff and one PA,
immediately transferred back to bed with six staff. Initial vital signs checked, BP-
76/61mmhg, HR-110bpm, O2 Sat-98%. At 1510H-RRT came, Placed patient on non
rebreather mask at 15lpm. Patient is combative and trying to remove the mask. Tried
to insert IV cannula but with difficult insertion. Patient became unresponsive, with
dilated pupils. At 1520H Code Blue activated. CPR started. At 1523H patient intubated
immediately and ambu bag ventilation started. Femoral vein cannulation tried by the
anesthesiologist but unsuccessful. At 1535H first dose of Adrenaline given via ETT. At
1538H Second dose of Adrenaline given via ETT. At 1540H Code Blue team arrived. At
1545H Intraosseous access inserted at right and left proximal tibia. Five doses of
Adrenaline 1mg given via Intraosseous was given every 3 minutes during CPR. IVF NSS
1liter given. Patient did not respond to CPR, only PEA. Patient was declared dead at
1605H.

The team should address the following questions during debrief:


# Questions Yes No Comments
1 Was communication in the event was
clear?
2 Were roles and responsibilities
understood?
3 Was situation awareness maintained?
4 Was workload distribution equitable?
5 Was task assistance requested or offered?
6 Were errors made?
7 Were errors avoided?
8 Were resource available?

• What went well?

The RRT/ Code Blue team came on time, it runs smoothly and efficiently. The team
leader and other team members are cooperative and have constant communication
with all other members on the code team.

• What should improve?


We should improve and ensure that all resources are available in the unit. For this kind
of scenario that patient has difficuty of Intravenous Access, all the needed equipments
should be readily available (e.g. CVP line, PICC, Intraosseous) to prevent unnecessary
delays.

Team Leader:__________________ Corp#:___________________ Date:_____________

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