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PSNet: Patient Safety Network
Journal Article

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-308.

Lack of appropriate situational awareness is an important source of diagnostic errors. One particularly dramatic outcome of poor situational awareness is an unanticipated transfer to an intensive care unit (ICU) due to failure to identify and treat clinical deterioration in a hospitalized patient. This study aimed to design a novel care system at a large pediatric hospital that would improve situational awareness of clinically deteriorating patients and ultimately decrease serious safety events. The team utilized a number of overlapping interventions, including proactive risk identification, frequent multidisciplinary huddles, and implementation of mechanisms that promote a continuous learning organization. This comprehensive system was associated with an almost 50% reduction in "unrecognized situation awareness failures events" (UNSAFE) leading to ICU transfer.