Ways to avert potential patient care disasters

Recognize when patients have unmet needs

Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

An infant is born with severe neurological defects following the mother's prolonged labor. Although the mother's labor is not progressing as would be expected, no one on the health care team seems concerned about the lack of progression until the unborn baby shows signs of fetal distress.

An elderly man in ICU is noted to have a distended, non-tender abdomen for several days. Over the same period of time, his blood pressure slowly drops and his heart rate steadily progresses upward from the 90s to the 120s. No one on the health care team appears to recognize these "weak signals" of an impending abdominal crisis until the patient's condition rapidly deteriorates. He dies following an emergency surgery for toxic megacolon.

Failing to recognize the significance of clinical warning signs, such as a prolonged labor or an increased heart rate, is a well-documented cause of unchecked patient deterioration that can lead to unexpected patient harm or death.

The investigation following these events usually doesn't uncover one particular individual at fault or pinpoint a blatant mistake made by the health care team.

Some hospitals are implementing medical emergency or rapid response teams to provide quicker responses when a patient exhibits the early warning signs of a potential medical emergency.

Yet, activating these teams requires that someone on the health care team recognize that a patient has unmet needs.

This may be easier said than done. Busy caregivers, who are already struggling to complete their daily list of tasks, may find it difficult to see the big picture in every patient. Potential clinical disasters cannot be averted by rapid response teams if caregivers fail to notice the warning signs.

There are several factors that influence whether caregivers recognize and respond to patient deterioration situations.

When conducting an investigation after an adverse event or proactively redesigning high-risk processes, it is important to recognize the underlying factors. Only then can targeted actions be designed to address these factors. Below are the common causes of failure to recognize/respond incidents.

Knowledge and Skill. Knowledge refers to an individual's understanding and ability to use information. Skill refers to the ability to perform tasks and task sequences at the right time and in the right order required for specific situations.

Errors due to lack of knowledge or skills include misinterpretation of information, misconceptions, forgetting or misapplying rules or instructions, use of wrong procedure for a given task or situation, missing a step or steps in a specific sequence, and loss of control due to lack of proficiency, or failure to follow prescribed procedures.

Attitudes. Attitudes refer to the combined belief, feeling, and intended behavior toward a particular person, idea, or situation.

Attitude errors are mainly unsafe acts or behaviors that are exemplified by such things as, habitual excess risk taking, over-estimation of ones abilities, anti-authority, and disregard for regulations.

Decision/Judgment. A failure to respond to a patient's changing clinical conditions can be due to limitations in an individual's ability to assess hazards and/or associated risks related to a particular situation.

Errors in this category can be subdivided into mistakes in judgment or violations.

Team Communication/Coordination. The health care team's ability to transmit (talk) and receive (listen) information using non-ambiguous language can affect patient care.

The team must be able to coordinate activities, divide tasks, and correctly interpret and act on information essential for safe patient care. Communication skills are known to be influenced by social, psychological, and group factors that sometimes create "social" communication barriers.

Team communication/coordination errors include: use of non-standard language, reluctance to talk or listen, failure to acknowledge a message (confirm by read back), failure to use all resources available, and (the most serious) failure to respond or act on a warning message from another team member.

Equipment/Systems. The ability for the health care team to see the big picture for all patients can be adversely affected by system and equipment design deficiencies, including poor control or display placement, inadequately displayed data, and poor documentation of system operation or maintenance procedures. These kinds of design problems contribute to different types of errors as well as increasing staff workload.

Supervisory. Leadership, culture, and organizational factors — the attitudes, policies, and practices established by those in command — can affect patient safety at the front lines. Other factors that fall into this category include the level of supervisory control and accountability for enforcing specific regulations, training, procedures, and quality control.

Supervisory-related errors include such things as non-supportive climate, failure to establish adequate standards, failure to monitor compliance to standards, and failure to discipline/ remove a known high-risk individual.

Reducing failure to respond to incidents

When caregivers do not recognize the signs of patient decompensation, the clinical response is inadequate or delayed. Determining why this occurs is the first step toward creating a safe patient care environment.

Rapid response teams are a proven intervention that hospitals can implement to help reduce unanticipated patient emergencies. However, this strategy should be supplemented with other actions. Listed below are some additional recommendations.

  • Increase proportions of nurses educated at the baccalaureate level or higher and nurses with specialist certifications.
  • Reinforce the concept of primary and secondary patient assessments. A primary assessment evaluates the patient's airway, breathing, and circulation.

A secondary assessment is a second look at the patient from head to toe after the ABCs have been addressed. Mentoring and simulation exercises are a good way to reinforce secondary assessment skills.

  • At staff meetings, discuss failure to respond to incidents. This should increase the ability of nurses and other caregivers to recognize the "weak signals," allowing for intervention before a manageable complication progresses to failure to rescue.
  • Encourage caregivers to step back and rethink initial assumptions if a patient's case takes an unexpected turn.
  • Get basic patient data, such as vitals signs and fluids, in electronic form and readily available to hospital staff.
  • Implement proactive clinical surveillance tools to identify patients who are failing to progress or decompensating. The ideal tools use electronic patient data.
  • Provide information tools that supervisors, charge nurses, hospitalists, and intensivists can use to see the big picture and aid patients in need at the earliest possible moment to avert potential clinical disasters.
  • Create communication protocols around handoffs — e.g., a standardized checklist.
  • Explore and address any environmental or cultural barriers to asking for help.
  • Clarify the lines of communication and responsibility between treating physicians, nurses, and other caregivers.
  • Train caregivers in use of assertive communication skills, e.g. S-BAR communication.
  • Encourage (and support) staff to go up the chain of command if questions or concerns are not answered.
  • Examine the medical staff peer review and/or the employee performance review process to determine if previous complaints about problematic practitioners or staff were dealt with in an adequate manner.

Whether caregivers recognize the significance of a patient's worrisome clinical signs is influenced by past experience. To improve recognition of early warning signs of patient decompensation, hospital staff educators should create experiential learning situations.

Some of the ways to accomplish this is by developing hands-on learning environments such as case studies, role plays, and story sharing. Individuals also should be encouraged to participate in team-based behavioral simulations in which they are confronted with the negative consequences of their usual ways of responding so they can see why these responses fall short.