Deteriorating patients: what, how, and why?

Learning from reports to the NPSA

Frances HealeyClinical reviewer, NPSA

Co-author NPSA deterioration reports

July 2007

WHAT goes wrong?• 424/576 deaths reported to the NRLS in 2005/06 occurred in

acute hospitals

• The review revealed 3 key themes:

– Diagnostic errors (n = 71)- Clinical deterioration not recognised or not acted upon (n

= 64)- Problems with resuscitation after cardiopulmonary

arrest (n = 43 in acute/general hospitals)

Updated analysis

Six months 1/9/07 – 29/2/08

Reported deterioration incidents with outcome of death = 41

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‘Sister came on duty at 7am. Called immediately to patient in side room seven. Patient unresponsive to painful stimuli. O2 sats below 80%, EWSS 4. No vital signs recorded from 11.30pm to 6.50am overnight. Doctor not called regarding low sats - patient post-op night. O2 sats were 83% at 11.30pm, question - why not rechecked? Patient condition deteriorated. Crash call called. S/B crash team, not suitable for ventilation. Patient passed away at 10.15am.’

Observations not taken…

Observations not taken…

• Not taking formal observations• Not making basic visual observations• Taking incomplete observations (especially no

respiratory rate)• Taking but not recording observations

“Patient found by accident on ward by Acute Pain Team on round, one day post op elective aortic aneurysm repair ……. First blood pressure recording 80 systolic - no action documented. Two further readings both hypotensive… Present staff still unaware of potential problem – blood pressure recorded by nurse prior to us seeing patient and systolic 95 – no action taken…”

Observations taken but deterioration not recognised.…

Observations taken but deterioration not recognised.…

• Not recognising observations are a cause for concern

• Calculating EWS incorrectly• Not seeing pattern from previous observations• Assuming it’s an equipment problem

“Patient unwell , returned to bed , ob 72% O2 , pulse 40, BP unobtainable . Dr A bleeped x 3 - no reply . Operator contacted for Dr B bleeped x 3 - no reply. Bleeped Dr C on call, stated too busy to attend and not covering unit. Tried to fast bleep Registrar x 3, unable to contact, could only hear talking in the background. Patients condition deteriorated, crash call put out ….. Resus efforts unsuccessful .”

Deterioration recognised but delay in receiving assistance

• Concern not effectively communicated

• Right person not contacted

• Person contacted unable to respond

Deterioration recognised but delay in receiving assistance

WHY does it WHY does it happen?happen?

November 2007

Method – triangulationMethod – triangulation

• Focus groups with doctors and nurses• Semi-structured interviews with clinicians • Aggregate Root Cause Analysis • Observational study and interviews• Literature review

Staffing and workload – the issues

• Time for formal observations

• Time for passing visual observation

• Competing tasks and busy times

• Understanding ‘outliers’ needs

• Numbers and skill mix and continuity

• Agency and bank

Are you encouraging colleagues to see observations as an important element of their work?

“When staff come on duty, they’ve got several must-dos. Patients must get their breakfast, drugs have to be given out and staff have to prepare for 10 o’clock hospital discharges. This is also the time to start ward rounds. There’s a lot of pressure in the early part of morning. So when do you fit in doing your obs?”

Team and social factors – the issues

• Strong and effective leadership• Clarity on roles and

responsibilities• Creating space and time to get

to know and trust colleagues

Do you have a suitably experienced ward leader on every shift who maintains an overview of the wellbeing of all patients?

“For some of the experienced nurses, you often hear people talk about the 'gut feeling'… you observe, you look closer, you question your patients. Somewhere along the line something will give information that a less experienced member of staff could overlook”

Communication and teamwork – the issues

• Key information handed over at shifts or ward transfers

• Being able to find the key information in notes• One picture to synthesise – results, notes, obs• Being able to communicate information succinctly

and to make requests assertively • Both nurses and doctors reluctant to seek more

senior help if they do not get the support they need from their first level contact

Equipment, individuals, and patient factors – the issues

• Basic maths errors• Lost skills to monitor without automated

equipment• Access to second hand watches or clocks• Language and culture• Patient seeing obs as unnecessary interruption

Monitoring and escalation procedures – the issues

• routine observations frequently carried out by healthcare assistants or student nurses

• Understanding the relevance of any findings and how to communicate these onwards

• ‘Trigger fatigue’• Complex contact systems• Clear and supportive escalation policies if no

appropriate response

What can you do?

• Enjoy and learn from the rest of today’s speakers

• Use the links to resources in the reports• Use the NPSA foresight training materials

www.npsa.nhs.uk/patientsafety/improvingpatientsafety

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 patient safety part of everything they do

– launch this summer

Further information can be found at:

www.npsa.nhs.uk

4 - 8 Maple Street, London, W1T 5HD