FAILURE TO RESCUE

[peady2]

Before Code Blue: Who’s minding the patient?
Little-known ‘failure to rescue’ is most common hospital safety mistake
Every year, at least 61,000 people die from "failure to rescue" mistakes, a new report found.

By JoNel Aleccia
Health writer
MSNBC

High-profile medical errors such as operating on the wrong body part or receiving a mistaken dose of drugs should take a back seat to a far more common and insidious mistake, a new report reveals.
For the fifth straight year, an analysis of errors in the nation’s hospitals found that the most reported patient safety risk is a little-known but always-fatal problem called “failure to rescue.”
The term refers to cases where caregivers fail to notice or respond when a patient is dying of preventable complications in a hospital.
Between 2004 and 2006, failure to rescue claimed more than 188,000 lives, amounting to about 128 deaths for every 1,000 patients at risk of complications, according to the latest report from HealthGrades, a health care ratings organization.

That’s far more than any other measure found in the new study, which detected 1.12 million safety problems during nearly 41 million hospital stays logged by the country’s Medicare recipients. The mistakes, tracked in 16 areas, accounted for more than 238,000 preventable deaths over three years and an estimated $8.8 billion in unnecessary medical costs, the report showed.

The numbers included 6-year-old Christian Padilla of Fort Wayne, Ind., who sailed through a successful heart surgery to correct a birth defect in 2005, only to die days later from the preventable complications that characterize a failure to rescue case.
“The nurse didn’t recognize his symptoms as something of concern,” said the boy’s father, Jim Padilla, 38, an assistant professor at a local university. “She described him in her medical notes as ‘acting fidgety.’”
In reality, the child was unconscious and suffering seizures as a result of the brain swelling that killed him, said Padilla, who received a $1.25 million combined settlement from the Indiana Patient’s Compensation Fund and Riley Children’s Hospital, according to the Indiana Department of Insurance.
It's not clear whether a drug reaction or another problem caused the swelling, said Padilla, who was at his son's side, frantic, throughout the ordeal.
"We got to the point where I had asked multiple times: 'Should he be sleeping so long?'" he said. "Over and over, I was told this was normal.'"
The nurse’s failure to notice Christian’s subtle but increasing symptoms of distress is a key element of this measure of how well hospitals respond to unexpected complications — or don’t, said Dr. Samantha Collier, chief medical officer for HealthGrades.
“As an example, somebody comes in for an elective surgery like a knee replacement and turns up with vague symptoms, like shortness of breath, and the next thing you know, somebody dies,” explained Collier. “It’s obvious that if you go in for a knee surgery, you shouldn’t die.”
When simple procedures go wrong

Failure to rescue is a marker that should concern anyone who’s ever been a patient in a hospital. It predicts whether even simple procedures suddenly could go wrong, said Dr. Michael DeVita, a professor of critical care medicine at the University of Pittsburgh School of Medicine.

“It’s before Code Blue,” he said, referring to the common term for patients in acute distress. “Somewhere between two-thirds and fourth-fifths of Code Blue incidents are preceded by this.”

Every year, at least 61,000 people die from failure to rescue mistakes, the report showed. The deaths have decreased by more than 11 percent since 2004, a bright spot in a study where about half of the patient safety indicators improved, but the rest didn’t. Four important post-operative indicators got worse: respiratory failure, pulmonary embolism or deep vein thrombosis, sepsis and abdominal wounds that split open after surgery.

Overall, the rate of patient safety problems has remained steady at about 3 percent of Medicare hospitalizations, the report indicated. The percent of patients who died after enduring one or more mistakes dropped by nearly 5 percent, to about 26 percent.

Although HealthGrades has been measuring failure to rescue since 2002, when it counted some 200,000 cases during a three-year reporting period, the agency has changed how it analyzes data from the federal Agency for Healthcare Research and Quality, Collier said.

Critics charged that the agency was including patients who might have been predisposed to complications, artificially inflating the results, but Collier said those patients have been excluded from the new analysis.

Still, even 11 percent improvement isn’t nearly enough in a condition that should be preventable, said Sean Clarke, associate director for the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia.

“Failure to rescue is not whether you get the wrong IV in the first place,” said Clarke. “It’s how fast do people pick up that you’re going south and turn it around?”

Too often, overworked, overwhelmed and inexperienced nurses and other hospital workers fail to notice basic problems, or to accurately interpret their meanings, said Clarke.

Surgery, painkillers raise risk

The two trickiest situations involve patients who’ve just come from surgery, or those who are taking medications for pain, Clarke said. In each case, subtle reactions can escalate from mild concern to near catastrophe within a matter of hours.

“It’s the basics. It’s about breathing, it’s about circulation, it’s about bleeding. Breathing issues are a huge, huge, huge deal,” he said.
The situation is hardly new. The term “failure to rescue” was first coined in the early 1990s by Dr. Jeffrey H. Silber, director of the Center for Health Outcomes and Policy Research. He was looking for a way to characterize the matrix of institutional and individual errors that contribute to patient deaths.

Staffing ratios aren't everything

The ratio of nurses to patients is one measure of how well a hospital might control its failure to rescue rate, Clarke said. Just as important, however, is the education and experience of the nurses and whether they have the resources available to do their jobs.

“You can have what looks like a beautiful ratio of four patients to one nurse on a unit, but depending on how sick they are, that might not be enough,” Clarke said. “And what about support? Is there someone there to answer the phone? Is there someone to get supplies?”

DeVita has spent two decades working to avert deaths caused by such lapses.

So far, the best way to deter the problem has been through the use of rapid response medical teams, DeVita said. Last year, small teams of specialists responded to 2,600 incidents in DeVita’s hospital, rushing to a patient’s bedside whenever several core triggers were tripped.

“The notion is to build an intensive care unit around any patient anywhere in the hospital building in just a few minutes,” said DeVita, who has cut unexpected deaths from 6.5 per 1,000 admissions to half that number.

The concept has been so successful that the Joint Commission, the national nonprofit hospital accreditation agency, now requires hospitals to have a system to detect patients in crisis and to respond immediately.

“For consumers, if a hospital doesn’t have a rapid response team, I think they shouldn’t be there,” DeVita said.

That’s only the first step patients and their families should take to avoid failure to rescue complications, said Collier. Family members should expect to become advocates for patients, watching for subtle signs of change and notifying staff if they occur.

“So let’s say Mom goes in and she was sharp as a tack before surgery,” Collier said. “You’re sitting there and suddenly mom’s not acting right. She knows who you are, but she thinks she’s at home. That’s the beginning of delirium.”

Similarly, shortness of breath could indicate a growing circulation problem, and nausea could be a sign of an imminent heart attack, she noted.

Call 'Condition H'

In growing numbers of hospitals across the country, patients are allowed, even encouraged, to speak up by activating ‘Condition H,’ a code that summons immediate help. Patients call the same emergency number that doctors and nurses use. Worries of false alarms have proved generally groundless, Collier said.

Still Clarke worries about burdening patients and family members with the responsibility of monitoring.

“The onus shouldn’t be on the patient to do our job,” he said.

True enough, Collier said. But if consumers want to be certain they’re not victims of the most common safety error in the country, they’ll take on some of the responsibility themselves.

“Patients need to know that care varies widely,” she said.

At Riley Children's Hospital, Christian Padilla's death sparked several changes, including an acute response team and a program that urges parents to seek information or voice concerns about their children's care, administrators said.

That's a comfort to Jim Padilla, now a volunteer patient advocate who often speaks to nurse's groups.

"I don't blame the nurses, I blame the system," he said. "But I still tell them, 'When you think you know the answer, you don't.'"
© 2008 MSNBC Interactive

[Hepburn]

I find it hard to believe that failure to rescue occurred more frequently than medicine errors, patient falls and lab errors. But it makles exciting press I guess.
Failure to rescue (or more accurately, failure to recognize signs that need rescuing--) is a MAJOR problem --because it's usually fatal when it happens. I cannot tell you how many times in the past few years I have come upon the patient and found them either dead, near dead or in serious trouble. I am always shocked at how such obvious signs such as restlessness, sudden serious pain, diaphoresis, pallor, cyanosis, confusion and abnormal breathing can escape people who supposedly went to nursing school. In fact, I don't even think you need to be a nurse to notice most of these signs.
I think that they fail to notice ALOT of things about a patient that make the difference between an astute nurse and a task oreinted employee.

[peady2]

Stats don't lie-although anyone with any basic knowledge of statistics is aware that they can be skewed to "prove" almost any hypothesis.
I agree with you that I have also seen RNs fail to accurately assess obvious signs/symptoms of impending distress in patients, or to just blow them off because they were too busy or overwhelmed to deal with them. I also think it is hard to assess obvious s/s when you don't lay eyes on a person for hours at a time, which I saw quite often in med surg because nurses just had too many patients and especially if one went sour, that one could easily tie up hours of your day, leaving the rest to basically fend for themselves with just a CNA. When I realized that I could no longer give optimal care to my med surg patients I left the field, although I truly loved the diversity of people and challenges that med surg offers. Now working in psychiatry it just blows my mind how frequently my coworkers (and I include doctors here) totally ignore/miss basic medical issues with our patients. What good is fixing their addiction and mental health issues if they die because nurses and doctors failed to recognize their need for basic medical care?

[copperrose]

I remember being in a BLS class once with a nurse who couldn't remember CPR. She was middle aged, had been in nursing a while and she had a terrible time remembering what to do. About a month later a code was called on her floor. I thought "Oh boy, I hope she wasn't the nurse."

[Jeepers]

Sadly, I have seen too many "failure to recognize" a deteriorating patient. Years ago, as a charge nurse I asked one nurse how Mr. So and So was doing. She told me he was OK, just "really lethargic". The angel on my shoulder told me to go look at the lethargic man. Lethargic my arse! He was in the midst of a CVA!!!!! Yikes!

[copperrose]

Years ago when I was a float the hospital where I worked put GYN pt's on the post partum floor. The post partum nurses freaked because they "didn't take care of old ladies" I would really hate to be a GYN patient and have a cardiac problem. Since I was giving one pt. cardiac meds, this was a possibility. This situation only happened to me once. I hope that someone decided this wasn't a good idea. Nothing against Post Partum nurses but they wouldn't have a clue if one of the GYN pt's developed chest pain or her O2 sat dropped.

[Edson!]

I found this post quite interesting...and believable.

Why? Well, I've seen too many things with patients in which stuff was blown off, ignored, or not given adequate attention or inquiry. So while there indeed may still be a lot of medical errors, there's a general lack of caring to know, explore, or go the extra mile IMO. That's merely my opinion of course; but the above article underlines my suspicions and the things I have witnessed over the years--stuff that still gives me nightmares.

[NRSKarenRN]

Check out:


from Agency for Healthcare Research and Quality:
Failure to Rescue - "Failure to rescue" is shorthand for failure to rescue (ie, prevent a clinically important deterioration, such as death or permanent disability) from a complication of an underlying illness (eg, cardiac arrest in a patient with acute myocardial infarction) or a complication of medical care (eg, 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 (eg, 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.

Initial studies of mortality and complication rates after surgical procedures indicated that lower rates of failure to rescue correlated with other plausible quality measures.(1,2) Rates of failure to rescue have since served as outcome measures in prominent studies of the impacts of nurse-staffing ratios (3,4) and nurse educational levels (5) on the quality of care. Examples of the specific "rescue-able" adverse occurrences in such studies include pneumonia, shock, cardiac arrest, upper gastrointestinal bleeding, sepsis, and deep venous thrombosis.(4) Death after any of these in-hospital occurrences would count as failure to rescue, on the view that early identification by providers can influence the risk of death.

Understanding the Influences on the Association between Nurse Staffing and Preventable Patient
Complications
www.ahsrhp.org/interestgroups/nursing/dangd.pdf


These studies should be used by VP nursing/DON to stress need for adequate staffing to improve patient care outcomes. Now that hospitals will be hit in the pocket books for "never events" and associated studies reflect reason why patients in the hospital in the first place: PATIENT ASSESSMENT AND NURSING CARE

[nyapa]

Too often, overworked, overwhelmed and inexperienced nurses and other hospital workers fail to notice basic problems, or to accurately interpret their meanings, said Clarke... and whether they have the resources available to do their jobs.

Jim Padilla, now a volunteer patient advocate who often speaks to nurse's groups:
"I don't blame the nurses, I blame the system," he said. "But I still tell them, 'When you think you know the answer, you don't.'"
© 2008 MSNBC Interactive

What does this show us?
1. Nurses are the first to be blamed. Often we report things, but they do not get followed up - failure to rescue can also be the responsibility of doctors...

2.Research is showing that education, staff numbers, and resources have a big impact on the safety of hospital clients. As such, hospitals are close to being negligent in not addressing these issues...

[Miami_NightNurse]

What does this show us?
1. Nurses are the first to be blamed. Often we report things, but they do not get followed up - failure to rescue can also be the responsibility of doctors...

2.Research is showing that education, staff numbers, and resources have a big impact on the safety of hospital clients. As such, hospitals are close to being negligent in not addressing these issues...

I agree!!! And then they don't do anything to retain nurses so that they can gain the experience needed to be able to recognize when things are starting to go down hill.

[kitty29]

This is interesting - in our pt. population(NICU) I feel this may not be a big of an issue - we are basically spoiled in our unit anyway - good staffing, experienced staff who have a sixth sence and doctors who listen to their nurses!