Acta Scientific Women's Health (ASWH)(ISSN: 2582-3205)

Case Study Volume 5 Issue 4

Failure to Rescue” A Life Support Case Presentation Dilemma

Manfred Mortell RN*

Department of School of Nursing and Allied Health Professions, University of the Bahamas, Bahamas

*Corresponding Author: Manfred Mortell RN, Department of School of Nursing and Allied Health Professions, University of the Bahamas, Bahamas.

Received: February 24, 2023; Published: March 30, 2023

Abstract

Failure to Rescue” is a foreboding concern that compromises patient safety and encourages morbidity and mortality from iatrogenic interrelated medical errors. The enquiry with the presentation of a case study, addressed in this short communication is, “why are patients “failing to be rescued” by healthcare providers (HCP)?” “Failure to Rescue” is a measure of quality of care and postulates that, while obstacles may replicate both the seriousness of the patient illness and the associated health care dynamics. The capacity to “rescue” patients once harm occurs is closely associated with the quality of health care provided. Sub-standard care, and risk incidents are often coupled with “Failure to Rescue” settings. One such “Failure to Rescue” and safety occurrence links to non-compliance by HCP when verifying and documenting correct and truthful inspections on “crash carts”. Failure to do so not only compromises patient safety, but also constructs the potential to injure patients, due to a failure of crash cart readiness. Research into the causes of “Failure to Rescue “reveals the complexity of the dilemma, with comparisons that reflect expertise into contextual factors such as organisational failure, deficit knowledge and skills, a dearth of supervision and inadequate staffing levels which in combination with excessive workloads creates time management burdens for HCP making it problematicfor them to prioritise their responsibilities. However, despite these contextual aspects it is the author's belief, that “Failure to Rescue” related to untruthful checking and documentation on “crash carts” correspondingly involves a “failure in ethics.” That failure being a deficit in an HCP obligation to their duty of care which safeguards patients and protects them from harm if advanced life support is required. The author assumes there is a predicament with ethics where theory and practice integrate, and consequently, malfeasance. We as HCP are forsaking our duty as patient advocates.

 Keywords: Emergency Trolley; Ethics; Failure to Rescue; Practice; Theory

References

  1. The Joint Commission National Patient Safety Goals (2017).
  2. Davis RE., et al. “Patient involvement in patient safety: How willing are patients to participate?” BMJ Quality and Safety1 (2011): 108-114.
  3. Elder N and Dovey S. “Classification of medical errors and preventable adverse events in primary care: A synthesis of the literature”. Journal of Family Practice 11 (2002): 927-932.
  4. WHO Guidelines for Safe Surgery: Safe Surgery Saves Lives (2019)?
  5. Vincent C. “Patient Safety, 2nd edition”. Oxford: Wiley Blackwell (2010).
  6. Institute of Medicine (IOM). “To Err Is Human: Building a Safer Health System”. Washington DC: National Academy Press (2000).
  7. O'neill O. “Safe Births: Everybody’s business. King's Fund (2008).
  8. Collaborative Health Care Patient Safety Organization (CHCPSO) Annual Report (2020).
  9. Beydon L., et al. “Adverse events with medical devices in anesthesia and intensive care unit patients recorded in the French safety database in 2005-2006”. Anaesthesiology2 (2010): 364-372.
  10. Ghaferi AA and Dimick JB. “Importance of teamwork, communication, and culture on failure-to-rescue in the elderly”. British Journal of Surgery 103 (2016): e45-e51.
  11. Duarte SCM., et al. “Adverse events, and safety in nursing care”. Revista Brasileira de Enfermagem 1 (2014): 144-154.
  12. Reason JT. “Human Error”. New York, NY: Cambridge: Cambridge University Press (1990).
  13. Argyris C and Schon D. “Theory in practice: Increasing professional effectiveness, San Francisco: Jossey-Bass” (1990).
  14. Leape LL. “Error in medicine”. JAMA 272 (1994): 1851-1857.
  15. Mortell M. “A Resuscitation Dilemma - Theory Practice Ethics. Is there a theory practice ethics gap?” Journal of the Saudi Heart Association1 (2009): 149-152.
  16. Leape LL. “Hospital readmissions following surgery turning complications into treasures”. Journal of the American Medical Association 5 (2015): 467-468.
  17. Wilson J. “Bridging the theory practice gap”. Australian Nursing Journal4 (2009): 25-26.
  18. Vincent C and Reason J. “Managing the risks of organizational accidents”. Burlington, VT: Ashgate Publishing Company (1999).
  19. Vincent C., et al. “Framework for analysing risk and safety in clinical medicine”. British Medical Journal7138 (1983): 1154-1157.
  20. Institute of Medicine (IOM). “Crossing the Quality Chasm: A New Health System for the 21st Century”. Washington, DC: National Academy Press (2001).
  21. Institute of Medicine (IOM). “Health IT and Patient Safety: Building Safer Systems for Better Care”. Washington, DC: National Academies Press (2012).
  22. Dixon-Woods M., et al. “Culture and Behavior in the English National Health Service: Overview of lessons from a large multi-method study”. BMJ Quality and Safety 23 (2014): 106-115.
  23. Makary MA and Daniel M. “Medical error-the third leading cause of death in the US”. BMJ 353 (2016): i2139.
  24. Hodgkinson A., et al. “Preventable medication harm across health care settings: a systematic review and meta-analysis”. BMC 353 (2020): i2139.
  25. Rodwin BA., et al. “Rate of Preventable Mortality in Hospitalized Patients: A Systematic Review and Meta-analysis”. Journal of General Internal Medicine 7 (2020): 2099-2106.
  26. Bochner F., et al. “Controversies in treatment: how can hospitals ration drugs?” British Medical Journal 308 (1994): 123-127.
  27. Silber JH., et al. “Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue”. Medical Care 30 (1992): 615-629.
  28. Ghaferi AA., et al. “Hospital characteristics associated with failure to rescue from complications after pancreatectomy”. Journal of the American College of Surgeons 211 (2010): 325-330.
  29. Wakeam E., et al. “Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance”. JAMA Surgery 149 (2014): 229-235.
  30. Singh H., et al. “Measures to Improve Diagnostic Safety in Clinical Practice”. Journal of Patient Safety4 (2019): 311-316.
  31. Ghaferi AA and Dimick JB. “Importance of teamwork, communication, and culture on failure-to-rescue in the elderly”. British Journal of Surgery 103 (2016): e45-e51.
  32. American Heart Association Guidelines for CPR and ECC. Circulation 112 (2021).
  33. Patient Safety Authority: Clinical Emergency. Are You Ready in Any Setting?” Pennsylvania Patient Safety Advisory2 (2010): 52-60.
  34. Reason J. “Human errors: model sand management”. BMJ7237 (2000): 768-770.
  35. Stranks J. “Human Factors and Behavioral Safety”. Butterworth-Heinemann (2007): 130-131.
  36. Duarte S., et al. “Adverse events and safety in nursing care”. Revista Brasileira de Enfermagem1 (2015): 144-154.
  37. Fowler F., et al. “Adverse events during hospitalization: Results of a patient survey”. Joint Commission Journal of Quality and Patient Safety10 (2008): 583-590.
  38. Classen DC., et al. “Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured”. Health Affairs Millwood4 (2011): 581-589.
  39. Hinno S., et al. “Hospital nurses’ work environment, quality of care provided and career plans”. International Nursing Review2 (2011): 255-262.
  40. James JT. “A new, evidence-based estimate of patient harms associated with hospital care”. Journal of Patient Safety3 (2013): 122-128.
  41. Wise J. Determinants of disparities between perceived and physiological risk of falling among elderly people: cohort study”. BMJ (2018): 360.
  42. Joint Commission. Maintain supplies during an emergency (2019).
  43. Resuscitation Council UK (2022).

Citation

Citation: Manfred Mortell RN. ““Failure to Rescue” A Life Support Case Presentation Dilemma". Acta Scientific Women's Health 5.4 (2023): 72-82.

Copyright

Copyright: © 2023 Manfred Mortell RN. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.




Metrics

Acceptance rate35%
Acceptance to publication20-30 days

Indexed In





News and Events


  • Certification for Review
    Acta Scientific certifies the Editors/reviewers for their review done towards the assigned articles of the respective journals.
  • Submission Timeline for Upcoming Issue
    The last date for submission of articles for regular Issues is May 30, 2024.
  • Publication Certificate
    Authors will be issued a "Publication Certificate" as a mark of appreciation for publishing their work.
  • Best Article of the Issue
    The Editors will elect one Best Article after each issue release. The authors of this article will be provided with a certificate of "Best Article of the Issue"
  • Welcoming Article Submission
    Acta Scientific delightfully welcomes active researchers for submission of articles towards the upcoming issue of respective journals.

Contact US