Source · HSSIB Patient Safety Investigation
Recognising and responding to critically unwell patients
Published 16 June 2021
Launched 12 October 2017
Published
HSIB Legacy
Communication and decision making
Hospital care
Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals. Previous research has shown that up to a quarter of preventable deaths are related to failures in clinical monitoring.
Summary
2 recommendations
1 of 2 responded
Safety Recommendations
R/2019/032
Royal College of Physicians
It is recommended that the Royal College of Physicians NEWS advisory group continues to evaluate the implementation and use of NEWS2, including but not limited to: The use of NEWS2 in practice, in particular the consistency of recording, the consistency of response, and the communication of patient measurements between healthcare professionals. The effectiveness of NEWS2 in identifying a patient’s level of acute illness in different care settings and patient groups. The presentation of NEWS2 information and how this supports clinicians to identify trends, particularly in electronic records. The guidance and training on the use of NEWS2 as part of clinical assessment and patient monitoring.
The Royal College of Physicians has formed a NEWS2 advisory group and committed to specific actions over the next 12 months including developing guidance, e-learning modules, working with electronic record providers, and sharing best practices.
Response received 7 August 2019
The Royal College of Physicians has formed the NEWS2 advisory group to evaluate the implementation and use of NEWS2 collaborating with system experts and leaders from NHS Improvement, NHS England, AHSNs [Academic Health Science Networks], the RCGP [Royal College of General Practitioners] and prominent healthcare professionals from the field of deterioration and sepsis. Through this group, and in part informed by this report, we recognise that there are key areas of focus including assessing the use of NEWS2 in practice and its effectiveness in identifying the level of acute illness in different patient groups and settings, how the presentation of NEWS2 supports clinicians to identify trends, and training on the use of NEWS2. Over the next 12 months we aim to: Provide, as appropriate, support to clinicians using NEWS2, for example, guidance around the new confusion score to be published within the RCP NEWS2 FAQs. Support the development of additional e-learning modules covering the common challenges faced by clinicians using NEWS2. Seek to work with companies that provide electronic recording platforms to move towards consistency of products for recording NEWS2. Ensure that the RCP NEWS2 website is an effective mechanism for sharing case studies of good practice and lessons learned from the implementation and use of NEWS2. Support the continuation of embedding NEWS2, and the learning from its use and implementation throughout the NHS. Response received on 7 August 2019.
R/2019/033
NHS England/NHS Improvement should expand the remit of the Cross-System Sepsis Programme Board to include physical patient deterioration, involving additional stakeholders as required.
HSIB makes the following safety observations
Observations:
NEWS2 is not intended to be a stand-alone tool. Instead, it is intended to be combined with other relevant charts, clinical investigation results and notes together with clinical observations of the patient. There may be benefits to staff being trained in this approach and systems being designed to support bringing relevant information together.
There may be benefits to including the historical data from NEWS2 graphs and charts, together with other key information, during a patient handover.
There would be benefits to trusts ensuring they are using the latest version of the NEWS2 observation chart and protocols. Any recommended changes to early warning scores, documentation or use would benefit from being tested in practice before widespread implementation.
No response published on HSSIB's website