title: Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.
abstract: BACKGROUND
  Because of the 80-hour work week, extensive service cross-coverage creates great potential for patient care errors. These patient care emergencies are increasingly managed using a rapid response team (RRT) to reduce patient morbidity. We examine the proximate causes of a surgical RRT activation. We hypothesize that most RRTs would occur during cross-coverage hours and be preventable or potentially preventable.
  
  
  METHODS
  All surgical RRTs more than a 15-month period were captured using a nursing database and the note from the staffing intensivist/fellow. RRTs were reviewed for appropriateness (pre-existing criteria) and proximate cause. Proximate causes were further classified as patient disease, team error, nursing error, or system error as well as preventable, potentially preventable, or nonpreventable.
  
  
  RESULTS
  Of 98 RRT activations, complete data were available for 82 (84%); 100% met activation criteria; and 76 (93%) occurred between 2100 and 0600. Seventy-six patients were 48 hours to 72 hours postoperative; six had nonoperatively managed injuries. The most common reason for activation was impending respiratory failure and acute volume overload (n = 72; 88%). RRT therapies included diuretics (n = 72), antiarrhythmics (n = 48), oxygen (n = 82), and bronchodilators (n = 36); only 2 received blood component therapy. Seventy-eight patients (95%) were transferred to higher level of care (61, surgical intensive care unit; 17, SSDU). Only 46% of patients required intubation. Performance improvement review identified 90% of physician related RRTs as preventable/potentially preventable because of errors in judgment or omission. Four RRTs because of patient disease were unpreventable. Two potentially preventable errors were each ascribed to RN or system concerns.
  
  
  CONCLUSIONS
  RRT activations principally result from team-based errors of omission, more often occur between 2100 and 0600, and are more often preventable or potentially preventable. Careful attention to fluid balance and medications for comorbid diseases would reduce RRT needs.
authors: Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, Connecticut 06520, USA. Lewis.Kaplan@yale.edu
authors: Lewis J
authors: LJ
authors: Kaplan
authors: Linda L
authors: LL
authors: Maerz
authors: Kevin
authors: K
authors: Schuster
authors: Felix
authors: F
authors: Lui
authors: Dirk
authors: D
authors: Johnson
authors: Daniel
authors: D
authors: Roesler
authors: Gina
authors: G
authors: Luckianow
authors: Kimberly A
authors: KA
authors: Davis
mesh_terms: D003422:Critical Care / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008505:Medical Staff, Hospital / Q000523:psychology*; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D014940:Work Schedule Tolerance / Q000523:psychology*; D016526:Workload / Q000523:psychology*