This report illustrates why deterioration incidents happen and offers practical help to NHS staff working in acute hospitals to improve patient safety.
Early identification of clinical deterioration is important in preventing subsequent cardiopulmonary arrest and to reduce mortality. However, sometimes patients’ conditions deteriorate before staff recognise and respond to the signs.
Analysis of 576 deaths reported to the National Reporting and Learning Service (NRLS) in 2005 identified that 11 per cent were as a result of deterioration not recognised or acted upon.
To investigate these incidents, the NRLS commissioned a programme of work to identify the underlying causes and contributing factors in deterioration incidents, and to explore how these factors interrelate.
The findings indicate that consistently and effectively detecting and acting on patient deterioration is a complex issue. Points where the process can fail include:
- not taking observations;
- not recognising early signs of deterioration;
- not communicating observations causing concern; and
- not responding to these appropriately.
The report recommends that:
- Every acute trust should strive to improve the safety of patients who are vulnerable to unexpected deterioration by establishing a deterioration recognition group.
- Trusts should also learn from their local equivalents of the data sources used to develop this report.