title: Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients.
abstract: OBJECTIVE
  To systematically risk assess and analyze the escalation of care process in surgery so as to identify problems and provide recommendations for intervention.
  
  
  BACKGROUND
  The ability to escalate care appropriately when managing deteriorating patients is a hallmark of surgical competence and safe postoperative care. Healthcare-Failure-Mode-Effects-Analysis (HFMEA) is a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended.
  
  
  METHODS
  Forty-two hours of ethnographic observations on surgical wards in 3 London hospitals (phase 1) formed the basis of an escalation process diagram. A risk-assessment survey identified failures associated with process steps and attributed hazard scores (phase 2). Patient safety and clinical risk experts validated hazard scores through a group consensus meeting (phase 3). Hazardous failures were taken forward to multidisciplinary HFMEA where cause analysis was applied and interventions were recommended (phase 4).
  
  
  RESULTS
  Observations identified 33 steps in the escalation process. The risk-assessment survey (30 surgical staff members, 100% response) and expert consensus group identified 18 hazardous failures associated with these steps. The HFMEA team identified 3 adequately controlled failures; therefore, 15 were subjected to cause analysis. Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure. Participants recommended interventions based on these findings including defined escalation protocols, human factors education, enhanced communication technology, and improved clinical supervision.
  
  
  CONCLUSIONS
  Failures in the escalation process amenable to intervention were systematically identified. This mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.
authors.affiliation: *Centre for Patient Safety and †Centre for Health Policy, Department of Surgery and Cancer, Imperial College London; and ‡Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Johnston
authors.forename: Sonal
authors.initials: S
authors.lastname: Arora
authors.forename: Oliver
authors.initials: O
authors.lastname: Anderson
authors.forename: Dominic
authors.initials: D
authors.lastname: King
authors.forename: Nebil
authors.initials: N
authors.lastname: Behar
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
mesh_terms: D006801:Humans; D007400:Interprofessional Relations; D008505:Medical Staff, Hospital / Q000592:standards; D009741:Nursing Staff, Hospital / Q000592:standards; D010348:Patient Care Team / Q000592:standards; D061214:Patient Safety; D010820:Physicians / Q000592:standards; D011182:Postoperative Care / Q000379:methods* / Q000592:standards*; D011183:Postoperative Complications / Q000517:prevention & control*; D018570:Risk Assessment / Q000379:methods; D013503:Surgery Department, Hospital / Q000592:standards*