Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18:3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
Investigators CMETIS, Cheung W, Sahai V, et al. Med J Aust. 2014;201:528-31.
Rapid response teams, while controversial, have become a mainstay of hospital efforts to identify patients at risk for acute deterioration. This survey of rapid response members, including physicians and nurses, sought to determine whether team activities adversely affected usual work responsibilities. Although there were no reports of patient harm associated with attending rapid response events instead of normal duties, team members did report significant disruption of usual routines and inconvenience to other staff and patients. Hospital incident reporting systems did not capture this unintended consequence of rapid response mobilization. These data add to the concerns about rapid response teams as a patient safety strategy. A past AHRQ WebM&M perspective covers lessons learned from early rapid response system implementation.
Jones D, Baldwin I, McIntyre T, et al. Qual Saf Health Care. 2006;15:427-32.
Medical emergency teams (METs, also known as rapid response teams) are being widely implemented in U.S. hospitals. Although their effectiveness in preventing adverse patient outcomes is uncertain, a major proposed benefit of such teams is to provide support for nursing staff. This study, conducted at an Australian hospital with a long-standing MET, surveyed ward nurses to determine if they understood the appropriate reasons to call the MET and evaluate if they felt the MET improved patient safety. Nearly all nurses felt the team helped provide more effective care for patients and helped educate nurses in caring for acutely ill patients. Nurses did not feel that they would be criticized for calling the MET. Despite the presence of objective criteria (eg, vital sign abnormalities) for calling the MET, most nurses preferred to use their clinical judgment to decide when to summon the team.
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