A 55-year-old man presented in hypotensive shock, presumably due to bacterial pneumonia superimposed on COPD. The nurse placed an arterial line appropriately in the patient’s radial artery for hemodynamic monitoring, but this line was inadvertently used to infuse an antibiotic. The patient experienced acute arterial thrombosis with resulting hand ischemia but responded to rapid thrombolytic and anticoagulant therapy.

A 66-year-old woman presented to the emergency department (ED) and was initiated on antibiotics and received fluid resuscitation for suspected urinary sepsis versus recurrent C. difficile colitis. However, the physical examination omitted an examination of her legs. Due to hospital overcrowding, the patient was kept in the ED overnight.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.¹ However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability.