Table 3

Unintended consequences of introducing safety systems

ThemesIllustrative problem associated with safety system
Routine monitoring practiceStaff experienced difficulty accessing observation data via the intelligent assessment technology at busy times/in emergencies:
‘before I could just go to a piece of paper and look at the trend … now I've got to log on, find the patient and get the last set of observations up' (nurse, 5, Eastward)
The intelligent assessment technology's prompts designed out a level of communication between nurse and healthcare assistant (HCA):
‘I would have to go and ask, “This patient, how often do you think I need to do these observations?” but now the [machine] tells me exactly what to do, I don't have to keep going to the staff nurse' (HCA, 3, Eastward)
Formalising understandings of deteriorationThe formalisation of certain markers included in the early warning score led to inattention to other additional important signs of deterioration:
‘Things such as blood results, are quite easily forgotten about when patients are not triggering … A lot of the junior nursing staff and some junior medical doctors don't recognise that someone needs really close monitoring because they've got really low potassium, they're on a cardiac monitor, but they may have a score of zero' (registrar, 7, Westward)
Summoning helpNormalisation of high early warning scores over time made it harder for lower level staff to escalate care:
‘if people score 5 or 6 continuously for days, and then don't look as good as they did yesterday, then that's harder for you to tell someone … If I said, “Mr B looks a lot worse today but their observations are exactly the same,” … it's harder for someone to see where you're coming from’ (nurse, 3, Westward)
Response behaviourThe critical care outreach team introduced further compartmentalisation:
‘You get this feeling sometimes of dead time, a patient is sick, it's identified that they need to go to the high dependency environment, but the time between identification and actually [moving] is viewed as though physiology stays still, and it doesn't … there's a “pass the problem” onto another group attitude' (consultant, 8, Westward)