Track signs of failing health to save more lives, hospitals told

‘The emphasis has to be on making sure the right information gets to the right place at the right time’

MANY patients’ lives could be saved if hospital staff noticed signs of deterioration and took action earlier, safety watchdogs say.

A new report has called for doctors and nurses to apply the same urgency to general decline in patients’ health as they are supposed to do in cases of sepsis, which are often fatal if not dealt with quickly.

A Healthcare Safety Investigation Branch (HSIB) inquiry was launched after the death of a 58-year-old woman admitted to hospital in pain 13 days after surgery for a perforated ulcer.

The inquiry found she died after medical staff failed to appreciate that her condition had worsened.

HSIB found that physiological readings, such as blood pressure, temperature and oxygen saturation, are too often recorded on separate forms, making it difficult to build an accurate picture.

The investigation also suggested that staffing structures in accident and emergency departments, as well as the controversial four-hour treatment target, may divert staff from tracking deterioration in patients.

Dr Stephen Drage, director of investigations at HSIB, said: “Our investigation very much highlighted that it is not easy to improve situation awareness and decision-making.

“The emphasis has to be on designing an effective system to make sure the right information is getting to the right place at the right time, creating a holistic picture of the patient.

“Recognising and treating deterioration is something clinicians have to deal with every day in busy hospitals.

“Ultimately, our safety recommendations are designed to reduce the devastating impact this has on staff, patients and their families.”