"Failure to rescue": most common hospital safety mistake

[Danbo1957]

This report was water-cooler material at our place, again:

http://www.msnbc.msn.com/id/24002334


(Please put in proper forum if necessary.)

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[docB]

In my facilities we have instituted "Rapid Response Teams" to address changes in status that don't rise to the level of a code. These teams are made up of Nursing Supervisors, ICU Charge Nurses and Respiratory Therapy. This team is called by the primary nurse and is called out overhead like a code. The team which brings a lot of experience to the bedside assesses the patient and discusses what interventions to carry out with the attending (usually by phone). This program has been very sucessful so far in terms of preventing codes and having the majority of codes happen in the ICU rather than on the floor.

 

[WallowaWanderer]

I like the idea of letting the patient, or the family, or the nurse, or the janitor, or anyone involved in that patient's hospital stay to activate some sort of alert system which brings to the bedside more than just a tired and overworked intern. It's sort of like the model that factories take when they allow anyone to stop production if they see something that's not right.

 

[Mary Jane Watson]

Our rapid response team or "MET" team includes a nurse, respiratory therapist, and an attending, who have to either be boarded in EM, critical care or anesthesia. It's nice to know if you're overwhelmed you have an attending trained in critical care/emergencies, as well as the ICU nurse/resp therapist there to help.

 

[VFTW]

I like the idea of letting the patient, or the family, or the nurse, or the janitor, or anyone involved in that patient's hospital stay to activate some sort of alert system which brings to the bedside more than just a tired and overworked intern. It's sort of like the model that factories take when they allow anyone to stop production if they see something that's not right.

Yeah but at least at our hospital, Condition H's do not activate the rapid response team, and are in general not treated with the same level of concern as other Conditions. Several times on rounds, if we were on a floor where a crisis or arrest was called overhead, the entire team would run to the room and take over the patient until the CCM team got there. When we heard a Condition H, everyone rolled their eyes and carried on with business, usually meaning that the charge nurse (who is required to check out what's going on in a Condition H) was the only person in the room. It doesn't activate the rapid response team, it just gets the patient attention from the charge nurse. And it has become a thorn in people's sides because it has often been abused by needier patients who are angered that their team will only give them 1mg Dilaudid q4 instead of the 2mg they wanted. It's a great idea in theory, these Condition H things, and has probably helped divert some crises in practice, but as if often the way with any patient-controlled system, it is also something open to abuse and subsequently, becomes something to take less seriously.

 

[WallowaWanderer]

Yeah but at least at our hospital, Condition H's do not activate the rapid response team, and are in general not treated with the same level of concern as other Conditions. Several times on rounds, if we were on a floor where a crisis or arrest was called overhead, the entire team would run to the room and take over the patient until the CCM team got there. When we heard a Condition H, everyone rolled their eyes and carried on with business, usually meaning that the charge nurse (who is required to check out what's going on in a Condition H) was the only person in the room. It doesn't activate the rapid response team, it just gets the patient attention from the charge nurse. And it has become a thorn in people's sides because it has often been abused by needier patients who are angered that their team will only give them 1mg Dilaudid q4 instead of the 2mg they wanted. It's a great idea in theory, these Condition H things, and has probably helped divert some crises in practice, but as if often the way with any patient-controlled system, it is also something open to abuse and subsequently, becomes something to take less seriously.

What does Condition H stand for?

 

[gutonc]

We have RRT (rapid response team) which brings ICU Charge RN, RT and MICU Fellow/Res to the bedside. Unfortunately, since ICU Charge RN and RT only have to disentangle themselves from SuDoKu, by the time the MICU fellow/res gets done w/ whatever crumping patient they've been dealing with in the unit, the decision has already been made that the pt needs ICU transfer and the MICU fellow/res just gets to play transport. Just call the Code and be honest about it. I've seen Code's called that get blown off faster than an RRT call.

 

[VFTW]

What does Condition H stand for?

Condition Help - can be activated by any patient, family member, visitor to the hospital, etc on a patient's behalf, at any time, for any reason.