Errors in the nursing management of a deteriorating patient

Abstract

Effective management of the deteriorating patient requires early recognition of the signs of deterioration, timely review and appropriate interventions. However, this does not always occur. Errors in the recognition and management of a deteriorating patient are rarely related to a single factor; rather they are a complex interaction of system and human factors. This article presents a case study focusing on understanding the factors that led to errors resulting in the death of a patient. Understanding the complex interaction of system and human factors enables the identification of strategies that could be used to decrease the likelihood of a similar incident occurring.

How do nurses use early warning system vital signs observation charts in rural, remote and regional health care facilities: A scoping review

“…factors contributing to a patient's death in the case study discussed by Gluyas. 9 In that study, it was identified that documentation on the vital signs observation charts used in the facility did not denote parameters outside normal limits and the chart did not detail protocols for escalation. Keene et al 17 state that EWS are effective in monitoring patients; however, the EWS efficacy is dependent on the accuracy and quality of vital sign documentation.…”

“…The proactive approach is more of a wait-and-see tactic when dealing with patients with abnormal vital signs. 16 In a case study involving an unexpected patient death, Gluyas 9 reported that a coroner's recommendation was to implement an early warning scoring system with structured communication protocols as the chart in use at that time was not designed to identify observations outside normal limits and did not detail how concerns could be escalated in a timely manner. This recommendation highlights the importance of EWS vital sign documentation chart design.…”

“…It was recommended that the facility adopt an EWS as a platform for nurses to communicate their concerns regarding patients' clinical status. 9 Protocols built into EWS guide the clinician to escalate care when predetermined aggregate scores are reached. Escalation of care may include increasing the frequency of vital signs observations and/or escalating care to multidisciplinary experts.…”

“…9,16 Rural health care facilities are often under-resourced, and nurses must manage acutely unwell patients with minimal support from other medical and clinical staff. 9 The impact of staff shortages and time restraints is particularly significant in the implementation and success of EWS, which may contribute to poor quality recording of vital signs. 16 Similar challenges were identified by Gluyas 9 who stated that sustainability of adequate health services is often threatened by a combination of workforce shortages and lack of resources.…”

“…Rural health care facilities are frequently under-resourced, and nurses manage acutely unwell patients with minimal support from other medical and clinical staff. 9,10 Findings from this scoping review will inform this topic area.…”