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Integrating a Rapid Response System into a Patient Safety Program

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Abstract

Since at least the publication of the Institute of Medicine’s report To Err Is Human,1 most healthcare organizations have been struggling to find and eliminate hazards. Their struggle arises from the complex mixture of issues that plague any organization dealing with the seemingly easy problems to be solved by a new safety program. Many healthcare organizations soon realize they are dealing with organizational psychology issues that require tools from change management. Somewhat fewer facilities are aware of the problems ingrained in human factors engineering of systems, devices, and tools. We will define these terms and how they apply to Rapid Response Systems (RRS) and their efferent limb, the Medical Emergency Team (MET) and Rapid Response Team (RRT) throughout this chapter. An MET or RRT response is not just a wonderful tool to improve morbidity and mortality associated with hospital medical crises and cardiopulmonary resuscitation, it is also an indirect tool to address the struggles to improve quality and safety throughout a healthcare organization. Conceptually and empirically, most hospitals will likely need RRS programs due to findings from human factors engineering and healthcare.

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References

  1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

    Google Scholar 

  2. Bagian JP, Gosbee JW, Lee CZ, Williams L, McKnight SD, Mannos DM. VA’s root cause analysis system in action. Jt Comm J Qual Improv. 2002;28:531–545.

    PubMed  Google Scholar 

  3. Stalhandske E, DeRosier J, Patail B, Gosbee JW. How to make the most of failure mode and effect analysis. Biomed Instrum Technol. 2003;37:96–102.

    Article  PubMed  Google Scholar 

  4. Weick KE, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in the Age of Complexity. San Francisco, CA: Jossey Bass; 2002.

    Google Scholar 

  5. Rodgers E. Diffusions of Innovations. 5th ed. New York: Free Press; 2003.

    Google Scholar 

  6. Sanders MS, McCormick EJ. Human Factors in Engineering and Design. 7th ed. New York: McGraw-Hill; 1993.

    Google Scholar 

  7. Gosbee JW, Lin L. The role of human factors engineering in medical device and medical system errors. In: Vincent C, ed. Clinical Risk Management: Enhancing Patient Safety. 2nd ed. London: BMJ; 2001.

    Google Scholar 

  8. Gosbee JW. Introduction to the human factors engineering series. Jt Comm J Qual Saf. 2004;30:215–219.

    PubMed  Google Scholar 

  9. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294–300.

    Article  CAS  PubMed  Google Scholar 

  10. Mattei LC, McKay U, Lepper MW, Soar J. Do nurses and physiotherapists require training to use an automated external defibrillator? Resuscitation. 2002;53:277–280.

    Article  PubMed  Google Scholar 

  11. Fairbanks RJ, Shah MN, Caplan S, Marks A, Bishop P. Defibrillator usability study among paramedics. In: Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting. Santa Monica, CA: Human Factors and Ergonomics Society; 2004.

    Google Scholar 

  12. McLaughlin RC. Redesigning the crash cart: usability testing improves one facility’s medication drawers. Am J Nurs. 2003;103:64A, 64D, 64G–64H.

    Google Scholar 

  13. Xiao Y, Hunter A, Mackenzie CF, Jeffries NJ, Horst R. The LOTAS Group. Task complexity in emergency medical care and its implications for team coordination. Hum Factors. 1996;38:636–645.

    Article  CAS  PubMed  Google Scholar 

  14. Xiao Y. Human and technology factors in coordination in emergencies. In: Medicine, Technology and Human Factors in Trauma Care: A Civilian and Military Perspective. Baltimore, MD: National Study Center; 2001:16–21.

    Google Scholar 

  15. Braithwaite RS, DeVita MA, Mahidhara R, Simmons RL, Stuart S, Foraida M. Medical Emergency Response Improvement Team (MERIT). Use of medical emergency team (MET) responses to detect medical errors. Qual Saf Health Care. 2004;13:255–259.

    Article  CAS  PubMed  Google Scholar 

  16. Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;179:283–287.

    PubMed  Google Scholar 

  17. Carroll JS, Rudolph JW, Hatakenaka S. Learning from high hazard organizations. In: Staw B, Kramer R, eds. Research in Organizational Behavior. Greenwich, CT: JAI; 2003.

    Google Scholar 

  18. Carroll JS, Rudolph JW, Hatakenaka S. Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qual Saf Health Care. 2002;11:266–269.

    Article  CAS  PubMed  Google Scholar 

  19. ECRI. An introduction to FMEA. Using failure mode and effects analysis to meet JCAHO’s proactive risk assessment requirement. Failure modes and effect analysis. Health Devices. 2002;31:223–226.

    Google Scholar 

  20. DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure mode and effect analysis: the VA National Center for Patient Safety’s prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248–267.

    PubMed  Google Scholar 

  21. Spath P. Worst practices used in conducting FMEA projects. Hosp Peer Rev. 2004;29:114–116.

    PubMed  Google Scholar 

  22. Foraida M, DeVita MA, Braithwaite RS, Stuart SA, Brooks MM, Simmons RL. Improving the utilization of medical crisis teams (Condition C) at an urban tertiary care hospital. J Crit Care. 2003;18:87–94.

    Article  PubMed  Google Scholar 

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Correspondence to John Gosbee .

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Gosbee, J. (2011). Integrating a Rapid Response System into a Patient Safety Program. In: DeVita, M., Hillman, K., Bellomo, R. (eds) Textbook of Rapid Response Systems. Springer, New York, NY. https://doi.org/10.1007/978-0-387-92853-1_4

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  • DOI: https://doi.org/10.1007/978-0-387-92853-1_4

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