We are not there yet: a qualitative system probing study of a hospital rapid response system.

Siri Lerstøl Olsen; Eldar Søreide; Britt Sætre Hansen

Study

We are not there yet: a qualitative system probing study of a hospital rapid response system.

April 20, 2022

Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;18(7):717-721.

View more articles from the same authors.

Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients. Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.

PubMed citation

Available at

Related Resources From the Same Author(s)

Reduction in omission events after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery.

March 15, 2023

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals.

May 26, 2021

Redeployment of health care workers in the COVID-19 pandemic: a qualitative study of health system leaders' strategies.

May 19, 2021

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.

July 22, 2020

Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience.

April 14, 2021

Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.

October 26, 2022

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

Usability and accessibility of publicly available patient safety databases.

June 1, 2022

Resilience from a stakeholder perspective: the role of next of kin in cancer care.

September 23, 2020

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

March 9, 2022

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study.

September 7, 2022

Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology.

May 19, 2021

Medication reconciliation during hospitalization and in hospital-home interface: an observational retrospective study.

April 7, 2021

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

COVID-19 and patient safety: time to tap into our investment in high reliability.

May 12, 2021

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

Teamwork before and during COVID-19: the good, the same, and the ugly….

August 24, 2022

The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department.

July 27, 2022

Feelings of trust and of safety are related facets of the patient's experience in surgery: a descriptive qualitative study in 80 patients.

August 24, 2022

Disparities in adverse event reporting for hospitalized children.

August 3, 2022

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

June 1, 2022

Detecting patient deterioration using artificial intelligence in a rapid response system.

March 25, 2020

Implementing high-reliability organization principles into practice: a rapid evidence review.

November 11, 2020

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Emergency physician perceptions of electronic health record usability and safety.

May 12, 2021

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.

August 17, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

May 11, 2022

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

June 15, 2022

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support.

May 18, 2022

Medication administration and interruptions in nursing homes: a qualitative observational study.

July 11, 2018

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

April 20, 2022

Race differences in a malpractice event database in a large healthcare system.

March 1, 2023

Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study.

August 11, 2021

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

Patient perceptions of hospital experiences: implications for innovations in patient safety.

March 16, 2022

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program.

April 13, 2022

National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies.

March 3, 2021

Family support role in hospital rapid response teams: a scoping review.

April 13, 2022

Predictors of serious opioid-related adverse drug events in hospitalized patients.

July 8, 2020

Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis.

February 23, 2022

A system-wide hospital child maltreatment patient safety program.

September 8, 2021

Characteristics of critical incident reporting systems in primary care: an international survey.

January 19, 2022

Should you reveal nonharmful mistakes to patients?

December 19, 2012

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

High-risk medication in home care nursing: a Delphi study.

September 7, 2022

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices.

October 28, 2020

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

January 1, 2022

Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework.

April 27, 2022

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

July 27, 2022

Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study.

September 23, 2020

Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States.

October 12, 2022

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events.

June 28, 2023

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

November 3, 2021

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.

November 10, 2021

Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study.

January 19, 2022

Suicide and suicide attempts on hospital grounds and clinic areas.

August 11, 2021

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.

June 16, 2021

The second victim: a contested term?

December 1, 2021

Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.

June 22, 2022

Evaluation of the culture of safety and quality in pediatric primary care practices.

July 6, 2022

Hospital surveys by the Centers for Medicare and Medicaid Services: an analysis of more than 34,000 deficiencies.

June 2, 2021

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Expert consensus on currently accepted measures of harm.

September 9, 2020

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.

July 28, 2021

Exploring system features of primary care practices that promote better providers' clinical work satisfaction: a qualitative comparative analysis.

May 18, 2022

Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study.

October 6, 2021

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg.

June 15, 2022

Cost of health care-associated infections in the United States.

March 23, 2022

The morbidity and mortality conference: opportunities for enhancing patient safety.

February 9, 2022

The impact of the built environment on patient falls in hospital rooms: an integrative review.

June 16, 2021

Safety in pediatric hospice and palliative care: a qualitative study.

September 23, 2020

Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.

April 27, 2022

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital.

April 27, 2022

Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.

September 21, 2022

The Sepsis Early Recognition and Response Initiative (SERRI).

March 9, 2016

Ambulatory virtual care during a pandemic: patient safety considerations.

March 9, 2022

Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients?

January 8, 2020

Race differences in reported "near miss" patient safety events in health care system high reliability organizations.

December 15, 2021

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.

November 30, 2022

Improving responses to safety incidents: we need to talk about justice.

February 23, 2022

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

June 8, 2022

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

A machine learning approach to reclassifying miscellaneous patient safety event reports.

July 29, 2020

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

December 9, 2020

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

Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee.

January 31, 2024

Supporting nurses in acute and emergency care settings to speak up.

November 8, 2023

Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival.

October 4, 2023

Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study.

September 20, 2023

Intensive care unit critical incident analysis as an objective tool to select content for a simulation curriculum.

September 13, 2023

In-situ simulations to detect patient safety threats during in-hospital cardiac arrest.

September 13, 2023

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

September 6, 2023

A multi-facetted patient safety resource--a qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team.

August 23, 2023

WebM&M Cases

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

July 31, 2023

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States.

June 21, 2023

Patient Safety Innovations

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

May 31, 2023

Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table.

May 3, 2023

Frontline nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: a qualitative study.

April 5, 2023

Exploration of ward-based nurses' perspectives on their preparedness to recognize clinical deterioration: a scoping review.

March 29, 2023

Reduction in omission events after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery.

March 15, 2023

Paediatric family activated rapid response interventions; qualitative systematic review.

January 18, 2023

Tele-Rapid Response Team (Tele-RRT): the effect of implementing patient safety network system on outcomes of medical patients- a before and after cohort study.

January 11, 2023

Examination of impact of after-hours admissions on hospital resource use, patient outcomes, and costs.

January 11, 2023

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

November 30, 2022

Journal Article

Commentary

Critical care resource nurse team: a patient safety and quality outcomes model.

November 16, 2022

Improving communication and response to clinical deterioration to increase patient safety in the intensive care unit.

October 19, 2022

Association of rapid response teams with hospital mortality in Medicare patients.

October 19, 2022

Exploring care left undone in pediatric nursing.

September 28, 2022

Effect of a rapid response team on the incidence of in-hospital mortality.

September 7, 2022

Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff.

August 31, 2022

Association between language use and ICU transfer and serious adverse events in hospitalized pediatric patients who experience rapid response activation.

August 17, 2022

July 20, 2022

Clinical progress note: situation awareness for clinical deterioration in hospitalized children.

May 11, 2022

See More About The Topic

Researchers

Hospitals

Intensive Care Units

Quality and Safety Professionals

Critical Care

We are not there yet: a qualitative system probing study of a hospital rapid response system.

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

Critical care resource nurse team: a patient safety and quality outcomes model.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

We are not there yet: a qualitative system probing study of a hospital rapid response system.

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

Critical care resource nurse team: a patient safety and quality outcomes model.

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