Safety Report Gives Insight Into Patient Deterioration

November 2017

Nursing

Country of origin: UK

A report, ?Recognising and responding appropriately to early signs of deterioration in hospitalised patients?, was launched recently at a conference ?Improving Patient Outcome ? Critical to Success? jointly organised by the National Patient Safety Agency (NPSA), the National Institute for Health and Clinical Excellence (NICE), the NHS Institute for Innovation and Improvement, Hospital at Night Team and the Department of Health.

The Agency first highlighted the issue of patient deterioration with its report ?Safer care for the acutely ill patient: learning from serious incidents? which included a detailed analysis of 576 deaths reported to the Agency?s National Reporting and Learning System (NRLS) over a one year period.

More than 11 per cent of these deaths related to patient deterioration not recognised or not acted upon and the NPSA pledged to carry out further work to explore the issue and identify contributing factors.

This new report is intended to be used in tandem with the National Institute for Health and Clinical Excellence (NICE) guideline on recognition and response to acute illness in hospitalised adults, launched in July 2007.

Dr Kevin Cleary, Medical Director at the National Patient Safety Agency, said: ?Patients should be able to feel confident that should their condition deteriorate in hospital, they are in the best place for prompt and effective treatment.

?However patients who are, or become, acutely unwell may not receive the best care because their deterioration is not recognised or might not be acted upon sufficiently quickly.

?Whilst the issue of deterioration is well recognised we felt it important to gain a better understanding of why these incidents occur. This report sets out why deterioration incidents happen and helps NHS staff working in acute hospitals to improve patient safety in this area in a very practical way. It includes a checklist of questions, a toolkit, links to a variety of resources and good practice examples, to help guide local action.?

Andrew Dillon, Chief Executive of NICE said: ?We welcome this report as a further contribution to improving patient care in this area. The NICE guideline published in July 2007, offers advice on the care of adult patients who are or become acutely while in hospital, and advises how serious problems can be avoided. I hope that NHS staff will use this report and the NICE guideline to significantly improve the care and safety of acutely ill patients. ?

The study found that common factors contributing to deterioration incidents include:

? Not taking observations
? Not recognising early signs of deterioration
? Not communicating observations that cause concern
? Challenges in prioritising competing demands
? Verbal and written communication breakdown
? Insufficient training to understand the relevance of observations
? A lack of successful implementation of relevant policies and procedures
? A lack of strong and effective ward leadership.

The NPSA is recommending that every acute trust sets up a multidisciplinary ?deterioration recognition group? to lead and coordinate efforts to improve the safety of patients who are vulnerable to deterioration. These groups should lead on reviewing local systems and processes and coordinating efforts to ensure optimum patient safety.

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