Complications are inevitable and they are not always avoidable or the result of errors. However, when a patient dies because of a complication that was not recognized in a timely manner or treated appropriately, that death is preventable and is called “Failure to Rescue.”
The eighth annual HealthGrades Patient Safety in American Hospitals Study looked at patient safety indicators for 40 million hospitalized patients. They concluded that many deaths and permanent disabilities could be avoided if hospitals adopted safe practices and implemented systems that facilitate patient safety.
The following patient safety indicators accounted for 68% of all patient safety events:
- Death among surgical inpatients with serious treatable complications
- Pressure ulcer
- Post-operative respiratory failure
- Post-operative sepsis
The cost associated with post-operative respiratory failure alone was $2 billion.2 In August 2012, the Joint Commission issued a sentinel event alert urging all hospitals to introduce measures to improve safety for patients receiving opiods, including systematic protocols to assess pain and appropriate opioid dosing, as well as continuous monitoring of oxygenation and ventilation.3
At the Patient Safety, Science & Technology Summit, an expert panel will review a variety of approaches that are available immediately for hospitals committed to reducing the frequency of Failure to Rescue through surveillance to identify patients at risk for Failure to Rescue, notification to providers of significant changes in patient condition, and automated decision support to ensure appropriate therapies are initiated in a timely manner. The panel will also explore the role of medical device interoperability and information sharing in eradicating Failure to Rescue.