Deterioration incidents: improving approaches

Deterioration not recognised or not acted upon, or failure to rescue, describes a now well documented and frequently occurring patient safety problem. Jones et al., define failure to rescue as “A failure to prevent a clinically important deterioration resulting from a complication of an underlying illness.”1 This is a failure on behalf of the healthcare team but also, fundamentally, of the system in which the team operates. All systems of healthcare are subject to latent failures and weaknesses, especially those that rely on human intervention, which are particularly vulnerable due to our innate propensity for error. James Reason has written extensively about system and human failure and the interconnection between the two. The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects. These include addressing “recurrent error traps in the workplace and the organisational processes that give rise to them”. Reason believes that “Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. A central idea is that of system defences.”2

Latent conditions

If latent conditions become aligned over successive levels of defence they create a window of opportunity for a patient safety incident to occur. Latent conditions also increase the likelihood that healthcare professionals will make “active errors” or create care delivery problems. When a combination of latent conditions and active errors causes all levels of defences to be breached a patient safety incident occurs.3 This is illustrated by the now well used Swiss Cheese Model. Deterioration incidents are a good example of “Swiss Cheese in action”. In many organisations, latent conditions exist around routine lack of compliance with observation protocols and response strategies/escalation protocols, lack of trained staff, complex track and trigger tools and ineffective methods of documentation and communication. These conditions produce weak, errorprone systems that set staff up to fail. When all of these prior conditions are in place, additional active failures, such as missing a patient’s observations or inability to contact a doctor, can lead to a patient safety incident and all too frequently, avoidable death. The deterioration scenario is now well recognised among health professionals, at least in acute care. A patient has been in hospital for a few days and his blood pressure begins to go down, his heart rate begins to go up, his urine output may reduce. Observations might be missed, particularly at night, and nursing staff do not recognise that he is getting sicker, the medical team are not alerted, and no action is taken to attempt to reverse this downhill spiral. Sometimes, the nurses are concerned and they do seek help, but it doesn’t come or it’s not enough or they are not able to convey the urgency of the situation. In any case, the action is not sufficient to change the outcome for the patient, which is an unsuccessful attempt to resuscitate from cardiac arrest. In 2007 the NPSA explored why this scenario continues to be so common and its report, “Recognising and responding appropriately to early signs of deterioration in hospitalised patient”4 highlighted the main contributory factors.