Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.
Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.
Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.
Rapid response teams (RRTs) are intended to quickly identify clinical deterioration and prevent intensive care unit transfer, cardiac arrest, or death. This article summarizes the evidence included in the AHRQ Making Healthcare Safer III report about the use of RRTs to decrease failure to rescue. Although utilization is widespread, the authors conclude that definitive evidence that RRTs are associated with reduced rates of failure to rescue is inconclusive. The authors note that evidence does support that RRTs are associated with reduced secondary outcomes, such as ICU transfer rate and cardiac arrest.
Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.
Lin DM, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131:e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
Failure to rescue is both a concept and a measure of hospital quality and safety. The concept captures the idea that systems should be able to rapidly identify and treat complications when they occur, while the measure has been defined as the inability to prevent death after a complication develops.
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