Deteriorating%20patients:%20what,%20how,%20and%20why?%20Learning%20from%20reports%20to%20the%20NPSA - PowerPoint PPT Presentation

View by Category
About This Presentation



'Patient unwell , returned to bed , ob 72% O2 , pulse 40, BP unobtainable. ... Patients must get their breakfast, drugs have to be given out and staff have to ... – PowerPoint PPT presentation

Number of Views:1121
Avg rating:3.0/5.0
Slides: 23
Provided by: NPS86
Learn more at:


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Deteriorating%20patients:%20what,%20how,%20and%20why?%20Learning%20from%20reports%20to%20the%20NPSA

Deteriorating patients what, how, and
why?Learning from reports to the NPSA
  • Frances Healey
  • Clinical 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

Observations not taken
  • 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
  • Not taking formal observations
  • Not making basic visual observations
  • Taking incomplete observations (especially no
    respiratory rate)
  • Taking but not recording observations

Observations taken but deterioration not
  • 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
  • Not recognising observations are a cause for
  • Calculating EWS incorrectly
  • Not seeing pattern from previous observations
  • Assuming its an equipment problem

Deterioration recognised but delay in receiving
  • 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
  • Concern not effectively communicated
  • Right person not contacted
  • Person contacted unable to respond


WHY does it happen? November 2007
Method 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
  • When staff come on duty, theyve got several
    must-dos. Patients must get their breakfast,
    drugs have to be given out and staff have to
    prepare for 10 oclock hospital discharges. This
    is also the time to start ward rounds. Theres 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

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
  • 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
  • Basic maths errors
  • Lost skills to monitor without automated
  • 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 todays speakers
  • Use the links to resources in the reports
  • Use the NPSA foresight training materials

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 4 - 8 Maple Street, London, W1T