Failure to Appreciate Status Changes/Deteriorating Patients

The positive impact of early identification and management of patient deterioration on clinical outcomes is well documented. The vast majority of catastrophic events are preceded by periods of physiological deterioration that is evident in vital signs prior to the event, such as temperature, heart rate (pulse), respiratory rate, blood pressure, oxygen saturation and level of consciousness. Often, family members identify changes in the patient’s behaviours such as the person’s alertness, level of awareness, as well as the restlessness and/or agitation. Delays in identifying deterioration of the patient’s status may not be recognized or acted upon by healthcare providers (HCPs) in a timely and appropriate manner can lead to negative patient outcomes. Closely monitoring physiologic and behavioural changes, maintaining levels of observation, conducting appropriate risk assessments and engaging family in consultations and communications are key to managing this risk.

Common claim themes


  • Perceived and actual tolerance of unprofessional, unsafe and/or disruptive as well as ongoing inter- and intra-professional conflicts impacting team communication and safe delivery of care.
  • Chaotic code (cardiac arrest) and resuscitation efforts.
  • Hesitancy to escalate concerns about unsafe practitioners and practices, including practitioners in leadership roles.

Knowledge and judgement

  • Failure to or delay in adequately identifying, assessing and responding to early signs of deterioration, in particular related to sepsis and neurological deterioration.
  • Ignored or bypassed physiological alarms and alerts due to alarm fatigue and practitioner ‘annoyance’, including those monitored centrally.
  • Normalizing and/or decreased vigilance over time towards:
    • Signs and symptoms of clinical deterioration; 
    • Patients’ responses medications administered.
  • Failure and delay to adjust the frequency of assessments and vitals as clinically indicated.
  • Failure to implement orders, particularly during the immediate post-operative period for patients in neuro-critical units (e.g., Q15 neuro assessments), intensive care units and post-operative anesthetic units.
  • Poorly designed and ineffective code and rapid response teams.

Communication and documentation

  • Disagreement among the health care team as to when and whether:
    • Orders and changes to orders were provided;  
    • A report and/or consultation took place.
  • Informal consultations, discussions and orders surrounding a deteriorating patient later disputed by one of the team members (e.g., hallway).
  • Delays communicating status changes to the most responsible practitioner (MRP), particularly overnight and early morning (e.g., wait until change of shift or morning rounds).
  • Dismissal of and/or failure to act upon patient and family concerns (e.g., agitation, pain, odd behavior).
  • Delays in calling code blue or resuscitation team.
  • Suspicious and self-serving late entries created following adverse events, in particular to clarify or defend why an order or care was not provided as per local guidelines.
  • Inconsistent and poor documentation of:
    • Scheduled and ‘periodic’ checks, vital signs and assessments, particularly overnight; 
    • Reports to and consults with the most responsible practitioner and/or on-call practitioners;
    • Verbal orders;
    • Actions taken in response to unremediated or ongoing care concerns;
    • Resuscitation efforts.

Case study 1

Following a cardiac surgery day procedure, the patient complained of burning sensation in the chest, feelings of restlessness and vomiting. Tachycardia was observed. The MRP was contacted and verbal order to continue IV fluids was provided. Throughout the evening and night, the patient continued to show signs of hemodynamic instability and became increasingly agitated. The alarm at the nursing station was activated and the patient was found unresponsive with a heart rate of 40 beats per minute.  Resuscitation efforts were initiated by the nurses and a code blue was called.  Ultimately, the patient was pronounced brain dead and supportive measures were withdrawn by the family. Expert review was not supportive of the nursing care; specifically failure on the part of the nurses to identify and communicate the tachycardia, hypotension and agitation to the MRP for over a nine hour period. This included the primary nurse as well as the charge nurse assigned to the bank of monitors at the nursing station. Experts also questioned the rationale for the nurses to turn away the Code Blue team upon arrival, delaying the patient’s resuscitation. The case was deemed indefensible from a standard of care perspective.

Case study 2

A pediatric patient presented to the Emergency Department with tachypnea and was admitted to hospital for investigation. The clinical status of the patient deteriorated over a six hour period. The patient was found without vital signs. Shortly after intubation, the patient sustained a prolonged bradycardia resulting in permanent neurological damage. Expert review of the interdisciplinary team’s care and management was not supportive, noting that the team under-evaluated the degree of the illness throughout the patient’s experience in both the ED and hospital admission. The clinical notes from the ED admission were described by peer experts as ‘abysmal’ as they did not provide any insight into the course of care or critical thinking of the team. Expert review noted a six hour gap in-between documentation of vital signs for a pediatric patient presenting with respiratory issues. The case was deemed indefensible from a standard of care perspective.

Mitigation strategies

Reliable Care Processes

  • Develop and implement policies, protocols and/or algorithms establishing expectations related to frequency, components and documentation of patient assessments (e.g., head to toe), vital signs monitoring and trending of values (e.g., temperature, heart rate, respiratory rate, blood pressure, pain levels); including patient-specific criteria for adjustments to frequency of monitoring.
  • Ensure appropriate practitioner skills mix and scope of practice in patient assignments to complement actual or potential patient acuity.
  • Establish evidence based criteria for assigning levels of patient observation (e.g., 1:1 nursing, constant observation).
  • Implement formal strategies to enhance the early detection of clinical deterioration across all sites and programs, such as:
    • Patient and family initiated escalations of care systems;
    • Practitioner activated early warning scoring systems;
    • Automated early warning score (integration of several physical parameters into one single variable).
  • Implement formal strategies to develop and maintain an environment which supports and expects:
    • Early response to suspected and actual clinical deterioration, including seeking assistance from peers and other resources (e.g., rapid response teams);
    • Assertive and respectful questioning and challenging of care decisions (in order to obtain clarity and/or to advance patient safety concerns);
    • Zero tolerance of intra- and inter-disciplinary bullying and intimidation.

Documentation and Communication

  • Adopt a standardized and effective communication processes (e.g., “CUS”, “CHAT”, “SBAR”) to communicate status changes: 
    • To the MRP;
    • To team leader or nursing leader designate;
    • Between care providers at handoffs;
    • To families and substitute decision makers.
  • Adopt formal program and/or site-specific:
    • On-call and second on-call contingency plans (e.g., specific action to be taken when the on-call physician, practitioner or team does not respond or is unable to respond in an appropriate timeframe);
    • Chain of command ‘escalation’ process, including the names, titles and contact information for team members in the line of authority.

Strategies for practitioners

  • Ensure complete and timely documentation of:
    • Patient assessments and vitals (all, not some), response to interventions and actions taken; 
    • Reports to and consultation with physicians (e.g., name of the physician, date and time the report or consult took place, the level of urgency and concern communicated, the physician’s anticipated response and attendance time, orders and recommendations, changes to the care pathway or plan).


  • Implement formal multifaceted and targeted safety strategies to support and enhance early detection and response to clinical deterioration (e.g., interdisciplinary workshops, in-situ simulations and emergency skill drills; sharing of learnings/trends from periodic chart audits and extracts, analysis of reported incidents and medical-legal matters).

Equipment and Technology

  • Implement formal strategies to:
    • Ensure intermittent and continuous physiological monitors are not used as a replacement for staff, ‘hands on’ observations and assessments, vital sign monitoring or documentation;
    • Reduce critical alarm and alert fatigue (e.g., customizing alerts settings where available, reviewing alert indicators, adequate staffing to respond to alerts, noise control facility design, sharing alert data reports with units, surveying staff attitude and concerns towards alerts);
    • Improve the effectiveness and efficacy of centralized physiological monitoring (e.g., having more than one person monitor the tiles or screens, limiting the duration of the monitoring shift).

Monitoring and Measuring

  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and adherence to:
    • Escalation and chain of command protocols;
    • On-call and second-call or backup plans;
    • Physician and non-physician attendance and response times from requests for a consult or attendance.
  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and team adherence to early detection and response to clinical deterioration-related policies and protocols, including (but not limited to):
    • Adoption of formal quality measures and indicators (e.g., proportion of patient charts audited with evidence of delayed physician notification or consultation by any team member; proportion of patients audited that have complete sets of core physiological observations documented as part of the last set of recorded observations);
    • Sharing of learnings from patient deterioration near miss and harm incidents with the interdisciplinary team(s) (e.g., learnings from chart audits, trigger tools, incident reports, team debriefs, critical incident and quality of care and quality improvement committee reviews, medical legal claims, coroner reports and related recommendations).


  • HIROC claims files.
  • Australian Commission on Safety and Quality in Healthcare. (2008). Recognizing and responding to clinical deterioration: Background paper.
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  • Canadian Patient Safety Institute. (n.d.) Deteriorating patient condition.
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  • Institute for Healthcare Improvement. (2009). Early warning systems. IHI Improvement Map.
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  • McGaughey J, Blackwood B, O’Halloran P, et al. (2010). Realistic evaluation of early warning systems and the acute life-threatening events: Recognition and treatment training course for early recognition and management of deteriorating ward-based patients: Research protocol. J Adv Nurs. 66(4):923-931.
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  • Vorwek J, King L. (2016). Consumer participation in early detection of the deteriorating patient and call activation to rapid response systems: A literature review. J Clin Nurs. 25(1-2):38-52.