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Why are deteriorating patients not recognised or not acted upon A multi-method approach. Kate Beaumont, Deterioration

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Why are deteriorating patients not recognised or not acted upon A multi-method approach. Kate Beaumont, Deterioration

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    1. Why are deteriorating patients not recognised or not acted upon? A multi-method approach. Kate Beaumont, Deterioration Project Lead/Strategy Advisor, NPSA Richard Thomson, Professor of Epidemiology and Public Health, Newcastle University (Director, E&R at NPSA until August 2007) Dagmar Luettel, Research Associate, NPSA

    3. What is the problem? Many patients with cardiopulmonary arrests show deterioration before the arrest; however, repeated studies reveal continuing failure to recognise or act upon patient deterioration.

    4. No observations for a prolonged period. (23%) No recognition of the importance of the deterioration and/or no action taken. (49%) Delay in the patient receiving medical attention, when deterioration had been detected and recognised. (28%)

    5.

    6. Method � triangulation Focus groups with doctors and nurses Semi-structured interviews with clinicians Aggregate Root Cause Analysis Ethnographic analysis (observational study and interviews) Literature review to seek to answer why

    7. The contributory factors Staff communication between and within professions, reluctance to lose face Staffing levels and workload prioritisation, competing demands Priority of nursing tasks observations low Knowledge and training Teamwork hierarchies, leadership, transience

    8. What can you do? Institute use of communication tool (SBAR/RSVP), EWS, escalation protocol Regular audit of recording of observations, including respiratory rate Review training, delegation, roles Ensure appropriately experienced and largely supernumerary ward leader Have in place outreach/appropriate support

    9. Recommendations of the report A �Deterioration Recognition Group� should: lead and coordinate improvement learn from other trusts � resources, good practice examples and contact details are provided in the report use the checklist of reflective questions within the report to identify effective implementation strategies

    11. Active failures are like mosquitoes. They can be swatted one by one, but they still keep coming. The best remedies are to create more effective defences and to drain the swamps in which they breed. The swamps, in this case, are the ever present latent conditions. James Reason

    12. Acknowledgements NHS nursing and medical staff who shared their experiences in the interviews and focus groups NHS risk managers who shared anonymised root cause analysis reports Researchers who conducted the studies for this report: Mary Dixon-Woods, Anu Suokas and Richard Lilford (Ethnographic analysis), Claire Blackett and Steve Cross (Aggregate Root Cause Analysis), Kristina Staley and Judy Wilson (Interviews with Clinicians), Kate Beaumont, Dagmar Luettel, Jane Carthey, Joanne Hillier, Alison Hugget, Louise Thomas (Focus groups) and Mig Muller (Literature review) Leroy Edozien, Jenny Firth-Cozens, Saxon Ridley, Charles Vincent, Patricia Young and Suzette Woodward who helped to explore the contributory factors

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