Table 1

A comparison of findings and recommendations using the themed review versus individual RCA investigation

Safety barrierFinding from themed review of 6 casesRecommendations from themed reviewFinding from individual RCAsRecommendations from RCAs
Identification of deterioration and frequency of observations increased as per policyIn all 6 cases, frequency of observation was not increased in Emergency Department (ED) setting. This was in part because the policy for ED is different to ward areas, and nurses do not have technology to prompt them to (A) increase observation time and (B) remind nurses to carry out observationsDue to bed capacity, patients are staying in ED for longer. Therefore, they are ‘ward’ patients in the wrong clinical context. An improvement/change is needed to refocus how ED manage patients who are ‘ward ready’ but are waiting for a bed. There needs to be a classification system put in where nurses are prompted to observe patients more frequently for example, extend observation policy to include ED and provide ED with technology to prompt nurses to respond to high National Early Warning Score (NEWS)
  1. Nurses did not increase observations as per observation policy

  2. Nurse did not carry out more frequent observations

All RCA recommendations related to:
  • Remind nurses to follow observation policy

  • Disseminate reminders to wards of policy and frequency of observations

Senior review of patientVariation in how senior review is conducted in the ED. In some cases, this senior review was done over the phone and therefore relied on all the information being passed to the senior reviewing clinician. In some cases, a decision to deescalate the patient’s care was due to incomplete assessment of the patient from the senior clinicianA uniformed way of assessing patients from senior clinicians needs to be sought. There are benefits and negatives of physical versus remote review of patients. An improvement is needed to standardise or understand in what context a remote assessment is not appropriate. For senior consultant group to review with junior doctors to assess options for improvement
  1. Senior doctor not able to attend patient to review

  2. Senior review affected by anchoring bias of one blood pressure which was normal as this only information communicated by reviewer

  3. Delay in doctor arriving to review patient due to operational pressures

  1. Remind junior doctors of need to follow-up if they have concerns

  2. Doctors to be reminded of need to use Situation, Background, Assessment, Recommendation (SBAR) communication when referring to senior review to ensure complete clinical picture

  3. Dissemination of case to governance meeting to raise awareness

Involvement from other MDT, for example, outreach teamIn all cases, had the patients been on an acute ward, they would have all been reviewed by an outreach team due to their high NEWS score. Outreach team do not attend ED due to acuity of patients and medical cover, however, for patients that are ‘ward’ ready but waiting for beds, this is a missed safety netA change is needed to assess how outreach team can identify ED patients who, without bed pressures, would otherwise be on the ward. For outreach team and ED to devise an improvement plan for how operational management of these patients will change with current bed pressures in hospitalNothing identified in 6 RCAsNothing identified in 6 RCAs
  • MDT, multidisciplinary team; RCA, root cause analysis.