Care – Monitoring

Service: Risk Management
Subject: Care

Patient/Client monitoring is largely dependent on intermittent observations and measurements of simple variables, such as blood pressure, heart rate and temperature, by the healthcare team.  Early identification and detection of patients at high risk or in the early stages of deterioration can trigger the appropriate notification to members of the healthcare team, in hospital or community settings, and/or rapid response team and affect changes to the plan of care.  In so doing, there is an increased likelihood of reducing the need for higher acuity care, reducing hospital length of stay, emergency department visits and admission costs and potential for improved outcomes.  This document contains information entered by HIROC subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.


  • Likelihood – 2.74
  • Impact – 3.70

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key controls/mitigation strategies

  • Tools, Supports and Resources:
    • Falls Screening
      • Visual cue for patients at risk (e.g. falls armbands, red socks etc.)
    • Increased monitoring and available supports in patient waiting areas:
      • Visual cues  for identified patients at risk; such as a specific holder of specified charts in Computerized Tomography (CT) room
      • Additional team attendants on days within medical imaging to provide dedicated portering support
      • Crash carts and Closed-circuit television (CCTV) cameras
      • Implementation of call bells in stretcher bays
    • Established criteria for utilization of Rapid Response Team (ICU outreach) or any other organizational specific response team
      • Rapid Response Nurse circulating through organization
    • Sepsis protocol – implementation of automated triggers
    • Early Warning System capacity in newly installed vital signs equipment at the bedside
    • Transfer of accountability tool
    • Safety Huddles                  
    • Client Services Risk Management Procedure (client assessment, home/environment assessment, chart reviews, client concerns/ satisfaction surveys, event reports, health/safety reports)
    • Quality of Care Review process
    • Adverse event reporting and debriefing
    • Event tracking management system
    • Acute Respiratory Illness Surveillance Policy
    • Care Coordinator process and monitoring (including linking patients with family physicians)
    • Performance management framework
    • Alignment of organization’s Quality Improvement Plan (QIP) indicator with community Service Provider Organizations (SPO) QIP
  • Pediatric/Neonate specific
    • Rigorous implementation of the Neonatal Jaundice Quality Based Procedure (QBP) Handbook
    • Annual Self- Assessment of HIROC Risk Reference Sheets for Neonatal Hyperbilirubinemia
    • Implementation of standardized policies, processes and algorithms to support the implementation of the Clinical Guidelines for Screening and Management of Hyperbilirubinemia in Term and Late Pre-Term Infants
    • Comprehensive ambulatory post discharge services available 7 days a week for Neonatal Hyperbilirubinemia follow up and breastfeeding support
  • Communication, Training/Education:
    • White board communication process in high risk areas (e.g. computerized tomography - CT)
    • Increase staff awareness of Rapid Response Team or any other organizational specific response team or resources for care in the community and how to access them
    • Enhanced communication between Medical Imaging and Patient Care Units
    • Communicating shared expectations and requirements within the healthcare team
    • Registered Nurse (RN) and Medical Radiology Technician (MRT)  training on monitoring
    • Education of nurses to understand the Three Factor Framework (ensures the right nurse is looking after the right patient) to foster  correct patient assignment
    • Review of all Code Blue cases for potential failure to recognize deterioration for learning opportunities
    • Comprehensive Newborn Discharge Summary is provided for all families at discharge, detailing bilirubin journey and follow-up appointments
    • Requirements in Service Provider Organizations (SPO) contracts for specializations and skills across service types
      • Service Provider Reporting
    • Performance Management Framework


  • Number of incidents related to inadequate assessment and clinical surveillance
  • Number of complaints related to inadequate assessment and clinical surveillance
  • Number of Code Blues and reviews
  • Number of Clinical Resource Nurse requests for support pertaining to assessment and monitoring
  • Number of critical incidents
  • Number of case reviews
  • Patient safety incident reporting:
    • Number of incidents related to monitoring/patient deterioration
    • Number of adverse events
    • Number of critical incidents with Failure to Rescue themes
    • Number of incident follow-up and near misses
  • Number of outreach calls
  • Sepsis protocol triggers (number of times the flag is raised; use of the secondary screen in Meditech; number of outreach calls)
  • Number of quality reviews related to unrecognized patient deterioration
  • Door to drug time for patients with sepsis in the Emergency Department
  • Audit process to ensure security/identification bands are numbered and placed in the system with babies names
    • Alarm systems that triggers if band not on, or goes outside area etc.
  • Length of Stay (LOS)
  • Quarterly audits on adherence to fetal status interpretation and response to abnormal fetal health status
  • Quarterly audits on adherence to oxytocin protocols
  • Percentage staff who completed fetal monitoring certification
  • Percentage patients who have a falls risk assessment completed on every shift
  • Quarterly audits on adherence to Obstetrical (OBS) chain of command protocols for calling physicians
  • Number of infant critical events reported to the Board
  • Number of Code Pink exercises completed per quarter
  • Audits of emergency records to ensure Canadian Emergency Department Triage and Acuity Scale (CTAS) is appropriate and complete
  • Tracking of Emergency Department (ED) patients who left without being seen
  • Track time of arrival to “seen by physician”
  • Compliance audits
  • Monitor ICU admissions from inpatient units