Case Archive
Pediatric Critical Care, Registered Nurse (Ped. Crit. Care)
Ref. # 18958

A 5 1/2 week old Texas boy was admitted to a medical center unequipped for newborn emergencies. The infant was in respiratory distress. Oxygen saturation was 47% on 100%. ABG's were 7.21/47/61/25. The diagnosis was pneumonia and the infant was taken to the center's nursery for newborns. The infant coded 13 minutes after arrival and again 45 minutes later. He died the next day. An autopsy confirmed bilateral bronchopneumonia. A medQuest specialist in pediatric critical care reported there was a negligent failure to intubate the infant on arrival in light of the grossly abnormal blood gas values and transfer him immediately to an appropriate medical center. A medQuest registered nurse specializing in pediatric critical care reported there was negligent care in the nursery. The infant's death was preventable.

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