One woman's untoward outcome has resulted in profound changes within a hospital system. Her complications have affected patients throughout the country and influenced the development of the Joint Commission's National Patient Safety Goals. This case study will describe how a series of errors culminated in a cardiac arrest. This program uses sldies, video clips, and photos to tell the story of how nursing, laboratory, and physicians contributed to her arrest. The session has an impact on those regarding the aftermath of errors.

Section Description

We are pleased to present the abstracts from sgna's 36th annual course, SGNA: your gateway to opportunity. The diversity of these topics certainly reflects the richness and breadth of our specialty. in keeping with the tradition of the annual course, we hope the following abstracts will encourage discussions for improving nursing practice and patient care outcomes.