Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events

摘要

BACKGROUND AND OBJECTIVE:Failure to recognize and treat clinical deterioration remains a source of serious preventable harm for hospitalized patients. We designed a system to identify, mitigate, and escalate patient risk by using principles of high-reliability organizations. We hypothesized that our novel care system would decrease transfers determined to be unrecognized situation awareness failures events (UNSAFE). These were defined as any transfer from an acute care floor to an ICU where the patient received intubation, inotropes, or ≥3 fluid boluses in first hour after arrival or before transfer.