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Journal Article > Commentary
Warrillow S, Bellomo R, Jones D. Jt Comm J Qual Patient Saf. 2007;33:112-117.
The authors present a case study of the use of a medical emergency team (MET) to manage a difficult airway in an elderly patient and the subsequent review of the incident by the clinical governance board.
Landro L. Wall Street Journal. July 11, 2007:D1.
This article reports on hospitals that are creating dedicated teams of experts who have the skills to perform risky medical procedures.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
Journal Article > Study
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
Shearer B, Marshall S, Buist MD, et al. BMJ Qual Saf. 2012;21:569-575.
Widespread enthusiasm for implementing rapid response systems (RRS) has been tempered in part by mixed impact on clinical outcomes. One argument for why RRS have not proven uniformly effective has been that they are underutilized in patients who might have benefited. Supporting that argument, this study found that 42% of adult patients with physiological instability failed to have an RRS activated despite meeting explicit written criteria. Furthermore, in these cases nearly 70% of providers recognized that the criteria were met and 76% were concerned about their patient, yet they did not activate the RRS. Structured interviews with staff members pointed to sociocultural reasons for failing to activate, and improved triggers and activation criteria were felt unlikely to have an impact. The authors conclude that local unwritten rules and culture may drive adherence to such written policies in more meaningful ways than the policies themselves.
Journal Article > Review
Al Kadri HM. J Emerg Trauma Shock. 2010;3:337-341.
This review explored the impact of medical emergency teams in obstetrics, and found little evidence on their use in this setting.
Journal Article > Study
In-situ interprofessional perinatal drills: the impact of a structured debrief on maximizing training while sensing patient safety threats.
Greer JA, Haischer-Rollo G, Delorey D, et al. Cureus. 2019;11:e4096.
This pre–post study examined the effect of team training on an emergency response team's performance in a perinatal emergency simulation. Following the training, performance in the simulation identified more latent safety threats and adherence to a safety checklist increased. The authors suggest that team training can enhance maternal safety.
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.