Thematic analysis of structured interview responses from the prospective data collection phase. All patients experienced a missed RRS call with an adverse clinical event
| Characteristics of interviewees | Frequency of responses (n=83), n (%) |
| Junior ward nurse | 28 (33.7) |
| Senior ward nurse | 16 (19.3) |
| Junior doctor (intern/resident) | 16 (19.3) |
| Senior doctor (registrar/consultant) | 13 (15.7) |
| Other (eg ICU outreach nurse) | 18 (21.7) |
| Actions performed prior to activating RRS | |
| Awaited further review or response by medical staff | 43 (51.8) |
| Specific treatment or investigations delaying RRS activation | 42 (50.6) |
| Involved ICU outreach or requested ICU review | 28 (33.7) |
| Involved senior nursing staff | 10 (12.0) |
| Explanation as to why RRS was not activated | |
| Felt the situation was under control in the ward setting | 45 (54.2) |
| ICU team already involved but no ICU bed was available | 25 (30.1) |
| Team involved were experienced in this type of patient and felt RRS activation was not required | 14 (16.9) |
| Poor communication/prioritisation by medical team | 13 (15.7) |
| Additional skills were not required to manage the patient | 8 (9.6) |
| No further clinical observations had been taken | 6 (7.2) |
| Altered thresholds for RRS activation but not documented | 4 (4.8) |
| Thought they were too junior to activate RRS | 1 (1.2) |
ICU, intensive care unit.