Preventing Failure to Rescue

Lewis_HeartrateHaving co-produced the patient safety educational film “The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman”, I have little doubt I have seen the film more than anyone else. I viewed the film once again at a recent patient safety meeting attended by Helen Haskell, Lewis’ mother, who led an interactive, educational discussion afterwards.  As many times as I have seen the film, I am repeatedly shocked and saddened when the chart showing Lewis’ heart rate over the last 48 hours of his life appears on the screen.

The faces of those in the audience reflect similar horror. The significant elevations in heart rate combined with the numerous changes in Lewis’ condition are so obvious to all of us in the audience playing “Monday morning quarterback”. We assume that those taking care of Lewis that weekend weren’t bad doctors or nurses. That they were all caring and compassionate, trying to do the best for Lewis, their patient…and yet they missed so many obvious warning signs predictive of pending doom. Why did this “inability to see the obvious” — or Failure to Rescue — happen with Lewis, and why does it continue to occur across the country with patients suffering similar harm?

Failure to Rescue is a well-known term in the patient safety arena. It is recognized as one of the more frequent and challenging causes of harm to patients around the world. Defined by the Association for Healthcare Research & Quality (AHRQ), failure to rescue is:

…shorthand for failure to rescue (i.e., prevent a clinically important deterioration, such as death or permanent disability) from a complication of an underlying illness (e.g., cardiac arrest in a patient with acute myocardial infarction) or a complication of medical care (e.g., major hemorrhage after thrombolysis for acute myocardial infarction). Failure to rescue thus provides a measure of the degree to which providers responded to adverse occurrences (e.g., hospital-acquired infections, cardiac arrest or shock) that developed on their watch. It may reflect the quality of monitoring, the effectiveness of actions taken once early complications are recognized, or both.

Human Factors colleagues remind us every day that humans are going to be human, and will make mistakes each and every day. They continue to tell us that until we build systems that take human tendencies out of the equation, we will continue to ask the impossible of our care teams, continue to put patients at risk, and continue to create clinical care environments that are doomed to fail.

To this end, there may be some good news on the horizon. Healthcare technology companies like Masimo and Cerner are making Failure to Rescue a top priority. Human Factors experts are now part of the conversation aimed at finding solutions. In addition, innovative safety leaders like Professor Cliff Hughes, the Chief Executive Officer at the Clinical Excellence Commission (CEC) in New South Wales, Australia, along with his CEC colleagues, have been redesigning clinical care models that are now showing early successes in preventing Failure to Rescue. Cliff has been a regular attendee at our Telluride Patient Safety Roundtable. He has also been long-time friend and wonderful mentor to me, and many others, over the years. The CEC program, called “Between the Flags“,  “is designed to establish a ‘safety net’ in all NSW public hospitals and healthcare facilities that reduces the risks of patients deteriorating unnoticed and ensures they receive appropriate care in response if they do”.

Screen Shot 2013-07-15 at 10.11.15 AMFrom the CEC website:

The Program uses the analogy of Surf Life Saving Australia’s Lifeguards and Life Savers who keep people safe by ensuring they are under close observation and rapidly rescue them, should something go wrong. The Between the Flags Program has a Five Element Strategy, which is essential to its long-term sustainability.

  1. A governance structure in each Local Health Network and hospital in NSW to oversee the implementation and sustainability of the Program.
  2. Standards for the criteria used for early recognition of the deteriorating patient (clinical observation and ‘track and trigger’ system), incorporated in standard observation charts e.g. the Standard Adult General Observation Chart (SAGO).
  3. Standards for a process for escalation of concern and rapid response to the deteriorating patient (Clinical Emergency Response System).
  4. Education packages for all staff to give them the knowledge and skills to confidently recognise and manage the deteriorating patient.
  5. Standards for key performance indicators to be collected, collated and used to inform the users of the system and those managing the implementation and continuation of the Program.

More on the Between the Flags program, diagnostic errors, conformational bias, premature closure and other issues related to Failure to Rescue in Part II…

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