Anonymous

Resuscitation Evaluation Form

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Information

Document No.
Audit Title
Client / Site
Conducted on
Prepared by
Location
Personnel

Timely response
Physician
ICU Code Team
Respiratory Therapy
Anesthesia
EKG/Orderly
Pharmacy
Phlebotomist
Radiology
Airway
- Delay
- Multiple Intubation Attempts
- Aspiration
- Misplacement/Displacement
Airway Attempts
Vascular Access
- Delay
- Infiltration/Disconnection
- Pneumothorax
- Inadvertant Arterial Cannulation
Chest Compressions
- Delay
- Inadequate depth/force to generate pulse
- Rib fractures
- No backboard
Defibrillation
- Delay
- Equipment Malfunction
- Indicated, not given
- Given, not indicated
- Wrong energy level
Medications
- Delay
- Selection
- Dose
Leadership
- Delay in identified leader
- Knowledge of roles
- Knowledge of medications
- Knowledge of equipment
- Poor team oversight
ACLS/PALS
- Protocol deviation
Equipment Availability
- Availability
- Function
Comments:

Anonymous

Resuscitation Evaluation Form

Use this Template

Print as PDF

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