1. Identify which tool(s) you would recommend using along with an explanation of why your team would select them and how they would be useful to analyze this event. 2. Use the tools of your choice to identify the problem statement and all possible failure points and contributing factors related to the core problem you have identified.
The Case
An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to
an inpatient psychiatry service for hallucinations and anxiety. On hospital day 2, he had sudden onset of
confusion, bradycardia, and hypotension. He lost consciousness, and a "code blue" was called.
The inpatient psychiatry facility is adjacent to a major academic medical center. Thus, the "code team"
(comprising a senior medical resident, medical intern, anesthesia resident, anesthesia attending, and critical
care nurse) within the main hospital was activated. The message announced through the overhead speaker
system, "Code blue, fourth floor psychiatry. Code blue, fourth floor psychiatry."
The senior resident and intern had never been to the psychiatry facility. "How do we get to psych?" the senior
resident asked a few other residents in a panic. "I don't know how to get there except to go outside and
through the front door," a colleague answered. The senior resident and intern ran down numerous flights of
stairs, outside the front of the hospital, down the block, into the psychiatry facility, and up four flights of stairs,
not knowing that the two buildings were connected on the fourth floor.
Upon arrival minutes later, they found the patient apneic. The nurses on the inpatient psychiatry ward had
placed an oxygen mask on the patient, but the patient was not receiving ventilatory support or chest
compressions. The resident and intern began basic life support (CPR with chest compressions) with the bagvalve-mask. When the critical care nurse and the rest of the code team arrived, they attempted to hook the
patient up to their portable monitor. Unfortunately, the leads on the monitor were incompatible with the
stickers on the patient, which were from the psychiatry floor (the stickers were more than 10 years old). The
team did not have appropriate leads to connect the monitor and sent a nurse back to the main hospital to
obtain compatible stickers. In the meantime, the patient remained with an uncertain rhythm. Moreover,
despite ventilation with the bag-valve-mask, the patient's saturations remained less than 80%. After minutes of
trying to determine the cause, it was discovered that the mask had been attached to the oxygen nozzle on the
wall, but the oxygen had not initially been turned on by the nursing staff. The oxygen was turned on, the
patient's saturations started to rise, and the anesthesiologist prepared to intubate the patient. Chest
compressions continued.
At this point, a staff nurse on the psychiatry floor came into the room, recognized the patient, and shouted,
"Stop! Stop! He's a no code!" Confusion ensued—some team members stopped while others continued the
resuscitation. A review of the chart showed no documentation of a "Do Not Resuscitate" order, the
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resuscitation continued. The intern on the team called the patient's son, who confirmed the patient's desire to
not be resuscitated. The efforts were stopped, and the patient died moments later.
Case Study Review:
Your group is selected for an improvement team in response to this event. Review the event and reflect on the
tools you have learned for problem solving and root cause analysis (5 Why’s, Driver Diagram, PDSA, GEMBA,
Fishbone diagram).
1. Identify which tool(s) you would recommend using along with an explanation of why your team would
select them and how they would be useful to analyze this event.
2. Use the tools of your choice to identify the problem statement and all possible failure points and
contributing factors related to the core problem you have identified.
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