The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

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

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Axelsen MS, Baumgarten M, Egholm CL, et al. J Adv Nurs. 2023;Epub Jun 30.

Rapid response teams (RRT) are activated, typically by nurses, when a patient demonstrates signs of imminent clinical deterioration, in order to prevent death or transfer to the intensive care unit (ICU). This study asks ICU managers about their perceptions of RRT beyond the stated goal of preventing patient deterioration. They describe the RRT as providing valuable education for new nurses and physicians and enhancing cohesion between the ICU and other wards. However, nurse managers stated they wanted more data and feedback from executive leadership.

Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration

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Patient Safety Innovation June 14, 2023

To address a well-documented hospital adverse outcome (in-hospital patient clinical deterioration), Kaiser Permanente Northern California (KPNC) developed and implemented the Advance Alert Monitor (AAM) program. Using predictive analytics, the team developed a model to alert clinicians up to 12 hours prior to a patient’s likely deterioration. This early detection allowed clinicians to devise and implement a care plan to prevent deterioration of the patient’s condition and/or align the care plan with the goals of the patient.

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

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

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

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Subbe CP, Hughes DA, Lewis S, et al. BMJ Open. 2023;13:e065819.

Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value.

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

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Dresser S, Teel C, Peltzer J. Int J Nurs Stud. 2023;139:104436.

Understanding how nurses use their clinical judgment in activating early warning systems or rapid response teams is important in improving response to deteriorating patients. Interviews with 20 nurses revealed an overarching sense of responsibility to their patients, eight subthemes including experience, making sense of the data, and a culture of teamwork.

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

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Mikhail J, King L. J Patient Saf. 2023;19:99-109.

Early recognition of warning signs of deterioration is key to activating the rapid response system (RRS) and prevention of serious adverse events. This review sought to understand how preparedness of ward-based nurses supports recognition of early warning signs and activation of RRS. Themes include knowledge of criteria to activate the RRS and deference to organizational hierarchy.

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

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Olsen SL, Nedrebø BS, Strand K, et al. BMC Health Serv Res. 2023;23:179.

Regular monitoring of vital signs is key to early identification of patient deterioration and provision of rapid response. This hospital in Norway determined inconsistent documentation of vital signs could be a barrier to successful implementation of a rapid response system (RRS). During the decade following introduction and refinement of the RRS, the number of completed vital sign sets increased, as did intensive care consultation, another component of RRS. Overall the RSS was associated with a reduction of in-hospital and 30-day mortality rates.

The role of language barriers on efficacy of rapid response teams.

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Raff L, Moore C, Raff E. Hosp Pract (1995). 2023;51:29-34.

Language barriers can lead to diminished care and threaten patient safety. This retrospective study included patients with rapid response team (RRT) activation and compared disease severity and outcomes for patients whose primary language was Spanish versus English. Findings suggest that language barriers may contribute to delays in RRT activation and delays in care.

Paediatric family activated rapid response interventions; qualitative systematic review.

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Cresham Fox S, Taylor N, Marufu TC, et al. Intensive Crit Care Nurs. 2023;2023:103363.

While many hospitals have rapid response teams (RRT) which can be activated by clinicians, only a few hospitals have also implemented programs which allow patients and families to activate RRT. This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. The authors of the review conclude that family-activated RRT is a key component to family engagement and enhancing patient safety. Only one intervention was also available in a non-English language, which should be considered in future interventions.

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.

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Balshi AN, Al-Odat MA, Alharthy AM, et al. PLoS ONE. 2022;17:e0277992.

Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.

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

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Patient Safety Innovation November 16, 2022

Rapid response teams are intended to improve timely identification and management of clinically deteriorating patients, such as in-hospital cardiac arrest or stroke.

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

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Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.

Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).

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

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Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.

Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.

Exploration of a rapid response team model of care: a descriptive dual methods study.

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Shiell A, Fry M, Elliott D, et al. Intensive Crit Care Nurs. 2022;73:103294.

Rapid response team (RRT) activations bring together a team of providers to immediately assess and treat a patient who is rapidly deteriorating. This mixed-methods study examined the characteristics of a collaborative RRT model in one Australian tertiary care hospital. The majority of activations occurred in general medicine units and some patients (approximately 5%) had more than five activations. Qualitative interviews with nurses and physicians highlighted how the collaborative RRT model improves patient safety and optimized early detection and management of patient deterioration.

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

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Factora F, Maheshwari K, Khanna S, et al. Anesth Analg. 2022;135:595-604.

Rapid response teams (RRT) are designed to intervene at the earliest signs of clinical deterioration to prevent intensive care unit transfer, cardiac arrest, or death. This study presents the changes of in-hospital mortality rates following implementation of RRT, introduction of anesthesiologist-led RRT, and other policy changes. Results indicate a gradual decline of in-hospital mortality in the nine-year period following RRT introduction.

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

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Thiele L, Flabouris A, Thompson C. PLoS ONE. 2022;17:e0269921.

Patient and family engagement is essential for safe healthcare. This single-site study found that while most clinicians perceived that patients and families are able to recognize clinical deterioration, clinicians expressed less favorable perceptions towards escalation processes when patients or families have concerns about clinical deterioration.

Rapid response systems.

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Stevens JP. UpToDate. August 15, 2022.

Although rapid response programs have been advocated as promising patient safety strategies, the evidence regarding their benefits is mixed. This review provides an overview of rapid response systems, including key components and goals of the intervention. Further research is needed to provide justification on their use for adult patients.

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

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McDade JE, Olszewski AE, Qu P, et al. Front Pediatr. 2022;10:872060.

Language barriers can place patients at increased risk for adverse events and near misses. This retrospective cohort study found that rapid response team events for non-English speaking pediatric patients are more likely to result in transfer to the intensive care unit compared to English-speaking patients. However, researchers also found that increased use of interpreters can contribute to improved outcomes.

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Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2023;32:214-224.

Rapid response teams, also known as medical emergency teams (MET), are activated when a patient demonstrates signs of clinical deterioration to prevent transfer to intensive care, cardiac arrest, and death. MET activations were prospectively reviewed at two Australian hospitals to determine the proportion of activations due to medication-related harms and assess the preventability of the activation. 23% of MET activations were medication-related, and 63% of those were considered preventable. Most preventable activations were patients with hypertension, and prevention strategies should focus on these patients.

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