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Finding patients before they crash: the next major opportunity to improve patient safety
  1. David W Bates1,2,3,
  2. Eyal Zimlichman1,4
  1. 1Division of General Internal Medicine, The Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
  2. 2Partners Healthcare Systems, Inc, Wellesley, Boston, Massachusetts, USA
  3. 3Harvard Medical School, Boston, Massachusetts, USA
  4. 4Sheba Medical Center, Tel Hashomer, Israel
  1. Correspondence to Dr David W Bates, Division of General Internal Medicine, The Center for Patient Safety Research and Practice, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA 2120, USA; dbates{at}

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Adverse events cause large numbers of deaths in hospitals, and many more serious injuries. Often, however, it is difficult or impossible in a specific circumstance to determine whether or not the outcome would have been different with an earlier intervention.1 ,2 On the other hand, substantial evidence exists for many conditions—sepsis for example—showing that earlier, more aggressive intervention can improve patient outcomes, especially with the use of protocols or guidelines.3

Better monitoring of sick patients has been a major interest in hospitals for decades and was a major rationale for the development of intensive care units (ICUs). Much of the research on monitoring comes from intensive care. Patients on general wards (ie, outside ICUs) are increasingly sick, but the level of monitoring they receive varies substantially, with intervals between manual vital signs measurement easily spanning 8–12 h. Often patients have already decompensated to a significant extent before transfer to an ICU is contemplated.

We believe that the coming together of four major trends or innovations promises substantial improvements to patient outcomes by preventing this perennial problem of delayed recognition and management of deteriorating patients on general hospital wards. These trends include the uniform use of electronic health records in hospitals,4 major advances in physiological sensor development,5 the rapid adoption of mobile technologies,6 and the ability to perform analytics in the background to provide decision support at the point of care.7

Adoption rates for electronic health records in the USA have risen from approximately 20% to over 80% in recent years.8 Although the comprehensiveness of these records varies substantially, a high proportion include electronic vital signs, which offers major opportunities to improve the early detection and management of patients at risk of clinical deterioration. Other countries, such as the UK and Canada, currently lag …

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