Safer care for the acutely ill patient: learning from serious incident

This Patient Safety Observatory report analyses data received by the Reporting and Learning System in 2005, regarding acutely ill patients who were reported to have died following shortcomings in their care. The analysis identified safety problems related to patient deterioration and with resuscitation.

The National Reporting and Learning Service completed a detailed analysis of 1,804 serious incidents reported to have resulted in death. On review, this number was reduced to 576 deaths that could be interpreted as potentially avoidable and related to patient safety issues.

Three themes emerged:

1. Staff can take too long to recognise patients who are clinically or physiologically deteriorating. 
2. Staff do not always act to address this, once identified.
3. The right staff are not always available when and where patients have cardiac arrests.

The report recommends actions regarding patient deterioration and resuscitation, including: 

• better recognition of patients at risk of deterioration, or who have deteriorated; 
• monitoring of vital signs; 
• accurate interpretation of clinical findings;
• calling for help early and ensuring it arrives; 
• improving communication;
• better situation analysis; 
• regularly risk-assessing resuscitation processes;
• training; and 
• ensuring appropriate drugs and equipment are available.