Failure to Rescue

start

Failure to

Rescue

• Patient safety is at the heart of everything we do as nurses.
• These concepts are woven throughout the curriculum

Patient Safety

Vital Signs - NUR 110

We didn't pick up on clues that signify deterioration.

What does this mean?

We didn't intervene when we could have.

What does this mean?

“the failure to prevent a clinically important deterioration, such as death or permanent disability, from a complication of an underlying illness or a complication of medical care.” (AHRQ, 2019)

Definition:

Patient Safety: Failure to Rescue

Failure to Rescue

Vital Signs - NUR 110

What makes it hard to assess vital signs and recognize when to intervene? What’s normal and what’s not normal? Click each button to learn more.

Failure to Rescue

Failure to Rescue

Vital Signs - NUR 110

Acting on vital signs or assessment trends and escalating concerns if necessary.

Taking Action and Activating a Team Response

Recognizing when a patient is deteriorating.

Timely Intervention

Frequent monitoring and accurate assessments are important.

Surveillance and Assessment

What can you as the nurse do to prevent failure to rescue?

Failure to Rescue

Vital Signs - NUR 110

Urine Output of 200 mLs in a 12 hour shift

Blood Pressure 110/70

Heart rate of 140

Are these findings benign or pathological?

Failure to Rescue

Vital Signs - NUR 110

Do you ALWAYS count respiratory rates? Check an apical pulse for a full minute?

“A respiratory rate of 20 breaths/minute is one of the earliest indicators of clinical instability.” (Garvey, 2015)

Do we always assess vital signs accurately?

Failure to Rescue

Vital Signs - NUR 110

Patients who have an in hospital cardiac arrest show deterioration in vitals signs up to 24 hours prior to the event. Taking and reporting vital signs correctly can save a life!

Why does this matter?

Failure to Rescue

Vital Signs - NUR 110

AHRQ: https://psnet.ahrq.gov/webmm/case/416/Despite-Clues-Failed-to-Rescue Garvey, P.K. (2015). Failure to rescue: The nurse’s impact. MedSurg nursing, 24(3), p. 145-149.

References

Heart rate 140

For an adult, this would be concerning, but for an infant it would not.

Impediments

4. Failure to diagnose and treat properly.

Urine output of 200 mLs in a 12 hour shift.

For most of us, this would be abnormally low, but for a patient with kidney failure on dialysis, it might be their normal.

Impediments

2. Failure to communicate and escalate concerns.

Impediments

3. Failure to physically assess the patient.

Impediments:

1. Failure to recognize deterioration

Blood pressure 110/70

This is within normal limits for an adult patient. However, what if the patient normally has a blood pressure that is in the 150s/80s and they have not had any medicines to lower their blood pressure? The nurse should be concerned then. It's all about knowing your patient and their care.