Unintended consequences of introducing safety systems
| Themes | Illustrative problem associated with safety system |
| Routine monitoring practice | Staff 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 deterioration | The 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 help | Normalisation 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 behaviour | The 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) |