Why are deteriorating patients not recognised or not acted upon

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, ER at NPSA until August 2007)
• Dagmar Luettel, Research Associate, NPSA

2
(No Transcript)
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
An NPSA review of reported deaths showed that the
majority of deterioration incidents could be
attributed to

• 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

Why?
www.npsa.nhs.uk
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

10
National Patient Safety Campaign
Making patient safety part of everyday
healthcare a new national campaign to encourage
people and organisations in the NHS to make the
safety of our patients everyones highest
priority - launch July
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