Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients

Title: Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients
Authors: Johnston, M
Arora, S
Anderson, O
King, D
Behar, N
Darzi, A
Item Type: Journal Article
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 Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure.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.
Issue Date: 1-May-2015
Date of Acceptance: 1-May-2015
ISSN: 0003-4932
Publisher: Lippincott, Williams & Wilkins
Start Page: 831
End Page: 838
Journal / Book Title: Annals of Surgery
Volume: 261
Issue: 5
Copyright Statement: © 2015 Lippincott Williams & Wilkins, Inc. This is a non-final version of an article published in final form in Annals of Surgery : May 2015 - Volume 261 - Issue 5 - p831–838,
Sponsor/Funder: National Institute for Health Research
Funder's Grant Number: NF-SI-0510-10186
Keywords: Science & Technology
Life Sciences & Biomedicine
escalation of care
health care failure mode effects analysis
patient safety
risk assessment
Interprofessional Relations
Medical Staff, Hospital
Nursing Staff, Hospital
Patient Care Team
Patient Safety
Postoperative Care
Postoperative Complications
Risk Assessment
Surgery Department, Hospital
11 Medical And Health Sciences
Publication Status: Published
Online Publication Date: 2015-05-01
Appears in Collections:Division of Surgery
Faculty of Medicine

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