Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2022;Epub Jul 5.
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.
Bentley SK, Meshel A, Boehm L, et al. Adv Simul (Lond). 2022;7:15.
In situ simulations are an effective method to identify latent safety threats (LST). Seventy-four in situ cardiac arrest simulations were conducted in one hospital, identifying 106 unique LSTs. Four LSTs were deemed imminent safety threats and were immediately resolved following debrief; another 15 were prioritized as high-risk.
Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;Epub Apri 15.
People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.
Acorda DE, Bracken J, Abela K, et al. Jt Comm J Qual Patient Saf. 2022;48:196-204.
Rapid response (RR) systems are used to improve clinical outcomes and prevent transfer to ICU of patients demonstrating signs of rapid deterioration. To evaluate its RR system, one hospital’s pediatric department reviewed all REACT (Rapid Escalation After Critical Transfer) events (i.e., cardiopulmonary arrest and/or ventilation and/or hemodynamic support) which occurred within 24 hours of the RR. These reviews identified opportunities for systemwide improvements.
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.
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.
Ang D, Nieto K, Sutherland M, et al. Am Surg. 2022;88:587-596.
Patient safety indicators (PSI) are measures that focus on quality of care and potentially preventable adverse events. This study estimated odds of preventable mortality of older adults with traumatic injuries and identified the PSIs that are associated with the highest level of preventable mortality. Strategies to reduce preventable mortality in older adults are presented (e.g. utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy).
Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82:1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
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.
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.
Cho K-J, Kwon O, Kwon J-myoung, et al. Crit Care Med. 2020;48:e285-e289.
This study compared an artificial intelligence (AI)-based early warning system using machine learning with conventional trigger methods for predicting deterioration among hospitalized patients, defined as in-hospital cardiac arrest resulting in ICU admissions. The AI system accurately predicted deterioration and was more accurate than conventional methods, demonstrating its potential effectiveness in EHR-based rapid response systems.
Koers L, van Haperen M, Meijer CGF, et al. JAMA Surg. 2019;155:e194704.
Failure to rescue is a significant cause of morbidity and mortality and is often associated with human error. In this innovative study, the authors posit that the use of cognitive aids, which are prompts that can help practitioners’ complete evidence-based tasks (e.g. symptom-specific checklists, flowcharts, and clinical guidelines), could improve timely recognition and effective management of complications in a surgical population. The study randomized surgeons and nurses to manage deteriorating patients in simulated scenarios with or without the use of cognitive aids. Use of cognitive aids significantly reduced omitted critical management steps and failure to adhere to best practices.
Although disclosure of medical error to patients is difficult, it is an ethical responsibility. This article discusses situations involving patients who are incapacitated and unrepresented but have no surrogate present to assist in communication and care coordination. Despite this challenge, the author argues that the clinician and organization still have the responsibility to document what happened, communicate what is known, and rectify the mistake.
Surgical proficiency gained from performing a higher volume of certain procedures is associated with fewer errors. This study used data from the National Surgical Quality Improvement Program to examine uncommon procedures and their surgical complication rates, with and without trainee participation. As expected, uncommon operations entailed significant rates of morbidity and mortality. Resident involvement was associated with higher likelihood that a patient in distress would be successfully resuscitated but was also associated with a longer operative time. The authors suggest that simulation training for uncommon procedures for residents may improve outcomes. A PSNet perspective reflected on patient safety in surgery.
Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319:1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Jones A, Johnstone M-J. Aust Crit Care. 2017;30:219-223.
This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.
Failure-to-rescue is considered a potential contributing factor in the wide variations in surgical mortality rates. This review explored the evidence regarding the surgical mortality of older patients and found system factors that affected failure-to-rescue rates, including safety culture and access to technology. The authors suggest that teamwork and communication improvement can help reduce failure-to-rescue in this patient population.
Johnston MJ, Arora S, King D, et al. Surgery. 2015;157:752-63.
Failure to rescue—lack of adequate response to patient deterioration—has been associated with adverse patient outcomes, particularly in acute care settings. This systematic review found that high hospital volume and increased patient-to-nurse staffing ratios were associated with failure to rescue, suggesting that addressing these workforce issues may enhance ability to recognize and intervene for deteriorating patients.
Johnston M, Arora S, King D, et al. Surgery. 2014;155:989-94.
This interview study examined escalation of care, the process by which a patient's deteriorating clinical status is recognized and acted upon, among surgical patients. Attending surgeons, trainees, intensivists, and rapid response team members believe that protocols for escalation of care lack clarity and that there is a dearth of supervision from senior clinicians. Similar to studies of handoffs, direct conversation—either in person or via mobile phone—was deemed preferable to hospital paging systems. Participants identified communication training, explicit and clear protocols, and increased supervision as key to improving the care of deteriorating surgical patients. Accompanying editorials highlight the importance of communication and the need for a safety culture that supports multidisciplinary teams.
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