Search results for "Active Errors"
- Active Errors
- Failure to rescue
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Journal Article > Study
Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.
Jones A, Johnstone MJ. 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.
Journal Article > Review
A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.
Johnston MJ, Arora S, King D, et al. Surgery. 2015;157:752-763.
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.
Journal Article > Study
Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.
- Classic
Johnston M, Arora S, King D, Stroman L, Darzi A. Surgery. 2014;155:989-994.
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.
Journal Article > Commentary
Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.
Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.
This commentary reviews the death of a patient to identify factors that contributed to the incident, including cognitive biases and poor communication between clinicians, and recommends strategies to address them.
Journal Article > Study
Failure to rescue as a process measure to evaluate fetal safety during labor.
Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.
This study discovers that using selected failure to rescue process measures may help identify areas for improvement in perinatal care.