title: Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.
abstract: 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.
  
  
  METHODS
  The setting for our observational time series study was a quaternary care children's hospital. Before initiating tests of change, 2 investigators reviewed recent serious safety events (SSEs) and floor-to-ICU transfers. Collectively, 5 risk factors were associated with each event: family concerns, high-risk therapies, presence of an elevated early warning score, watcher/clinician gut feeling, and communication concerns. Using the model for improvement, an intervention was developed and tested to reliably and proactively identify patient risk and mitigate that risk through unit-based huddles. A 3-times daily inpatient huddle was added to ensure risks were escalated and addressed. Later, a "robust" and explicit plan for at-risk patients was developed and spread.
  
  
  RESULTS
  The rate of UNSAFE transfers per 10,000 non-ICU inpatient days was significantly reduced from 4.4 to 2.4 over the study period. The days between inpatient SSEs also increased significantly.
  
  
  CONCLUSIONS
  A reliable system to identify, mitigate, and escalate risk was associated with a near 50% reduction in UNSAFE transfers and SSEs.
authors.affiliation: Divisions of Hospital Medicine, The James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA. patrick.brady@cchmc.org
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Brady
authors.forename: Stephen
authors.initials: S
authors.lastname: Muething
authors.forename: Uma
authors.initials: U
authors.lastname: Kotagal
authors.forename: Marshall
authors.initials: M
authors.lastname: Ashby
authors.forename: Regan
authors.initials: R
authors.lastname: Gallagher
authors.forename: Dawn
authors.initials: D
authors.lastname: Hall
authors.forename: Marty
authors.initials: M
authors.lastname: Goodfriend
authors.forename: Christine
authors.initials: C
authors.lastname: White
authors.forename: Tracey M
authors.initials: TM
authors.lastname: Bracke
authors.forename: Victoria
authors.initials: V
authors.lastname: DeCastro
authors.forename: Maria
authors.initials: M
authors.lastname: Geiser
authors.forename: Jodi
authors.initials: J
authors.lastname: Simon
authors.forename: Karen M
authors.initials: KM
authors.lastname: Tucker
authors.forename: Jason
authors.initials: J
authors.lastname: Olivea
authors.forename: Patrick H
authors.initials: PH
authors.lastname: Conway
authors.forename: Derek S
authors.initials: DS
authors.lastname: Wheeler
mesh_terms: D001364:Awareness; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D015278:Intensive Care Units, Pediatric / Q000592:standards*; D061214:Patient Safety / Q000592:standards*; D012307:Risk Factors