Table 2

Benefits and challenges of safety systems at Eastward and Westward

Themes	Benefits and challenges of safety systems
Routine monitoring practice	Benefits
	Access to real-time data and trends via the intelligent assessment technology facilitated scrutiny of ward practices:
	‘You can see clearly the time of day [the nurses and HCAs] do observations and the dip at night time. I mean we found one ward that did no observations at night’ (manager, 20, Eastward)
	Access to real-time data via the intelligent assessment technology enabled prioritisation and team situation awareness:
	‘When the staff come on duty now, they look at the PDAs [personal digital assistants] and the scores … they’re actually planning and prioritising' (nurse, 8, Eastward)
	Inbuilt prompts via the intelligent assessment technology ensured staff took a full set of observations:
	‘You get picked up on every little thing now. You can’t miss out anything. [Before] you could just do the blood pressure or the respiratory rate' (HCA, 3, Eastward)
	Organisational standardisation of early warning scoring and use of a protocol facilitated completeness of observations and utilization of scores:
	‘The main benefits are that patients cannot be transferred anywhere without a full set of observations and a score, so it's standardised all round the Trust, everybody knows what's happening' (manager, 10, Westward)
Formalising understandings of deterioration	Benefits
	The intelligent assessment technology enabled remote viewing of observations:
	‘When we can look at the observations on a computer it’s really helpful, if there's a quick trend you're like, I'm coming over right now' (junior doctor, 11, Eastward)
	The early warning score shaped understandings:
	‘You can tell if the patient's blood pressure or whatever is outside normal realms, the score makes it more black and white and objective' (nurse, 4, Westward)
	The early warning score facilitated prioritisation:
	‘Scoring is really useful at night particularly with patients that I don't know or I haven't had a history from, it gives me concrete objective criteria to enable me to prioritise' (junior doctor, 7, Westward)
Summoning help	Benefits
	The intelligent assessment technology's scoring system and inbuilt prompts empowered staff to call for help:
	‘I look for the vital signs like the respiration, pulse, and blood pressure. This is what the machine says. The machine will tell you [that] you need to get the senior nurse’(HCA, 2, Eastward)
	The intelligent assessment technology enabled shared understandings via remote viewing:
	‘The doctor can see the trend anywhere in the hospital … I can be talking to them on the phone and they'll just say, “Hang on a minute, I'll just tap it up.” … usually what you get is, ‘Oh just check them again in half an hour and give me a call if there's any change’ (nurse, 5, Eastward)
	The early warning score helped with escalation of care across boundaries
	‘The score is useful … if you're handing over the phone in the middle of the night to someone you've never met before … they don't know your judgement and your experience, so it's kind of a physical … this is quite clear’ (nurse, 5, Westward)
	The critical care outreach team helped overcome delays due to professional hierarchies:
	‘A lot of the time it's the very junior doctors on the ward that the nurses will call. They'll come and look at the patient, and think, “I'm not so sure of my plan, I'll run it by my senior house officer [SHO]”, the SHO then comes and has a look and thinks, “I'm not so sure, I'll run it by my registrar”. The registrar review can be 2, 3, 4 hours down the line. One of the good things about having us is that we'll see them at the same time as the junior doctor, and say, “you know what, that plan's good, but perhaps your registrar should come and see them now”' (critical care nurse, 13, Westward)
	Challenges
	Where different early warning systems were in use at Eastward, scores were not routinely used to summon help:
	‘The nurses don't often phone you and tell you what the score is. I think in the whole year I've been told the score once’ (junior doctor, 10, Eastward)
Response behaviour	Benefits
	The critical care outreach team mediated boundaries between junior and senior medical staff and the interface between ward and critical care:
	‘[the team] help me co-ordinate [care] with the junior doctors that are out by themselves … they will communicate directly with me about patients that they think need a higher level of intervention’ (registrar, 8, Westward)
	The critical care outreach team provided an important additional ‘safety net’ for patients discharged from ICU:
	‘The critical care nurse looked at the patient on the ward and checked the observations were being done hourly. As his heart rate had settled, she said her only advice was to try and get a cardiology review for this patient. However she noted “while he had an open wound he probably would continue to have a tachycardia, which at the moment was uncompensated”’(Extract from field notes, 10, Westward)
	ChallengesLack of critical care outreach at Eastward
	Lack of a formalised response strategy introduced heterogeneity in response behaviour across the organization:
	‘Response is very variable, it depends on which specialty, which team it is, who the doctors are, you can get a potent mix of nurses and doctors on a ward that seems to be particularly bad for escalating [care]’ (consultant, 14, Eastward)