Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.

Lynne A. Donohue; Ruth Endacott

Study

Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.

January 20, 2010

Donohue LA, Endacott R. Intensive Crit Care Nurs. 2010;26(1):10-7.

View more articles from the same authors.

This qualitative study found that nurses relied on their clinical judgment, rather than formal track and trigger systems, to determine when a patient required urgent assistance.

PubMed citation

Available at

Related Resources From the Same Author(s)

'Even now it makes me angry': health care students' professionalism dilemma narratives.

August 6, 2014

Factors influencing family member perspectives on safety in the intensive care unit: a systematic review.

December 9, 2020

Blending evidence and innovation: improving intershift handoffs in a multihospital setting.

January 11, 2012

Artificial intelligence systems for complex decision-making in acute care medicine: a review.

March 13, 2019

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors.

July 19, 2017

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

April 23, 2008

Patterns of unexpected in-hospital deaths: a root cause analysis.

March 16, 2011

A comprehensive obstetrics patient safety program improves safety climate and culture.

April 20, 2011

Medication safety in primary care practice: results from a PPRNet quality improvement intervention.

July 11, 2012

How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.

September 28, 2011

Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults.

September 23, 2009

Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study.

March 6, 2005

'The ABC of Handover': impact on shift handover in the emergency department.

February 8, 2012

Development and validation of a tool to assess emergency physicians' nontechnical skills.

April 18, 2012

Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature.

April 18, 2012

Communication patterns in a UK emergency department.

October 10, 2007

An overlooked condition.

November 30, 2005

When does quality improvement count as research? Human subject protection and theories of knowledge.

March 6, 2005

A piece of my mind. Mistakes.

September 27, 2006

The combined effect of psychological and social capital in registered nurses experiencing second victimization: a structural equation model.

December 1, 2021

Monitoring during sedation given by non-anaesthetic doctors.

March 19, 2008

Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project.

February 27, 2013

Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study.

May 25, 2022

Teams under pressure in the emergency department: an interview study.

January 25, 2012

Case study research: the view from complexity science.

May 4, 2005

Developing critical thinking skills for delivering optimal care

July 28, 2021

Incident reporting in one UK accident and emergency department.

December 21, 2005

Predictors of gaps in patient safety and quality in U.S. hospitals.

December 21, 2016

Distracted practice: a concept analysis.

December 9, 2015

A process for analysis of sentinel events due to health care–associated infection.

November 28, 2007

Analysis and prioritization of near-miss adverse events in a radiology department.

May 11, 2011

Perspectives on patient and family engagement with reduction in harm: the forgotten voice.

August 15, 2018

Developing an intervention to reduce harm in hospitalized patients: patients and families in research.

December 5, 2018

Lehigh Valley Hospital: engaging patients and families.

October 12, 2005

The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient units.

May 20, 2015

Expert consensus on currently accepted measures of harm.

September 9, 2020

Look-alike and sound-alike medicines: risks and 'solutions.'

March 7, 2012

Community Health Systems’ ongoing journey to zero preventable harm.

December 6, 2023

Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative.

June 24, 2020

Setting priorities for patient safety: ethics, accountability, and public engagement.

September 2, 2009

Design of an evidence-based "second victim" curriculum for nurse anesthetists.

June 1, 2016

Computerised prescribing for safer medication ordering: still a work in progress.

November 18, 2015

Association of note quality and quality of care: a cross-sectional study.

April 23, 2014

A narrative review of the well-being and burnout of U.S. community pharmacists.

April 3, 2024

Speaking up during the COVID-19 pandemic: nurses' experiences of organizational disregard and silence.

February 1, 2023

Condition concern: an innovative response system for enhancing hospitalized patient care and safety.

February 2, 2011

Improving medication safety in primary care using electronic health records.

December 8, 2010

Nursing assessment of continuous vital sign surveillance to improve patient safety on the medical/surgical unit.

December 9, 2015

Using a Delphi method to identify human factors contributing to nursing errors.

October 4, 2017

The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors.

May 19, 2021

Examining medication errors in a tertiary hospital.

December 20, 2006

Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions.

November 24, 2010

The role of purple pens in learning to prescribe.

February 13, 2019

Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow.

October 2, 2013

Implementing safety hotlines: Stamford Health's experience and future opportunities.

September 19, 2018

Alcoholism and American healthcare: the case for a patient safety approach.

August 17, 2022

Rules, safety and the narrativisation of identity: a hospital operating theatre case study.

March 15, 2006

'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department.

January 18, 2006

Hospital implementation of computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey.

November 16, 2005

A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.

November 28, 2012

Infection control assessment of ambulatory surgical centers.

June 23, 2010

A multicentre observational study to evaluate a new tool to assess emergency physicians' non-technical skills.

August 8, 2012

Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement.

November 23, 2011

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.

May 28, 2008

Electronic health records and malpractice claims in office practice.

December 3, 2008

Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III.

March 27, 2005

The relationship between professional burnout and quality and safety in healthcare: a meta-analysis.

April 19, 2017

Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs.

June 27, 2018

The weekend effect in hospitalized patients: a meta-analysis.

October 11, 2017

Banning the handshake from the health care setting.

May 28, 2014

Delineation of risk through the exploration of a culture of safety in community home health.

November 7, 2007

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Building safer systems through critical occurrence reviews: nine years of learning.

November 10, 2010

Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders' perspectives.

June 12, 2019

The safety of emergency medicine.

November 25, 2015

A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people.

April 10, 2019

What methods are used to apply positive deviance within healthcare organisations? A systematic review.

March 2, 2016

TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records.

September 11, 2019

Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

January 11, 2012

Hospital nurses' perceptions of human factors contributing to nursing errors.

June 10, 2015

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans.

November 2, 2011

Systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration.

April 20, 2022

Prevention of failure to rescue in obstetric patients: a realist review.

November 10, 2021

Screening for medication errors using an outlier detection system.

February 8, 2017

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients.

April 21, 2005

Dealing honestly with an honest mistake.

January 20, 2010

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Physicians and electronic health records: a statewide survey.

March 21, 2007

Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator.

January 20, 2010

Experience of wrong site surgery and surgical marking practices among clinicians in the UK.

November 15, 2006

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

June 20, 2018

Negative behaviours in health care: prevalence and strategies.

February 20, 2019

Literacy and misunderstanding prescription drug labels.

December 13, 2006

Integrating patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population: a collaborative approach.

June 19, 2013

Improving medication error reporting in hospice care.

May 27, 2009

A systematic review of nursing practice workarounds.

October 19, 2022

Regulatory and policy barriers to effective clinical data exchange: lessons learned from MedsInfo-ED.

October 5, 2005

At risk care plans: a way to reduce readmissions and adverse events.

January 21, 2015

What are the experiences of team members involved in root cause analysis? A qualitative study.

December 20, 2023

Ten years later, alarm fatigue is still a safety concern.

September 20, 2023

Related Resources

Perspective

Artificial Intelligence and Patient Safety: Promise and Challenges

March 27, 2024

Interview

In Conversation with...Patrick Tighe about Artificial Intelligence

March 27, 2024

Patient falls while under supervision: trends from incident reporting.

July 5, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported breakdowns in care.

May 20, 2020

Incivility and clinical performance, teamwork, and emotions: a randomized controlled trial.

May 22, 2019

Balancing patient-centered and safe pain care for nonsurgical inpatients: clinical and managerial perspectives.

January 16, 2019

An electronic health record–based real-time analytics program for patient safety surveillance and improvement.

December 5, 2018

Description and factors associated with missed nursing care in an acute care community hospital.

October 17, 2018

Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry.

June 27, 2018

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

February 8, 2017

Engaging frontline staff in performance improvement: the American Organization of Nurse Executives implementation of Transforming Care at the Bedside collaborative.

February 3, 2016

Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.

January 27, 2016

Examining the relationship among ambulatory surgical settings work environment, nurses' characteristics, and medication errors reporting.

January 27, 2016

Patient participation in patient safety and nursing input—a systematic review.

October 1, 2014

What's that sound? Managing alarm fatigue.

September 24, 2014

The occurrence of adverse events potentially attributable to nursing care in medical units: cross sectional record review.

August 20, 2014

Sounding the alarm. Nurses, organizations work to address alarm fatigue.

November 20, 2013

Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.

May 22, 2013

Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: a team-level study.

January 23, 2013

The Daily Plan: including patients for safety's sake.

April 11, 2012

Identifying the latent failures underpinning medication administration errors: an exploratory study.

March 21, 2012

Improving patient safety and optimizing nursing teamwork using crew resource management techniques.

March 14, 2012

See More About The Topic

General Hospitals

Nurses

Nurse Managers

Quality and Safety Professionals

Nurse Care

Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site