Patient safety on the otolaryngology service: the role of an established rapid response system - AHRQ Patient Safety Network

Patient safety on the otolaryngology service: the role of an established rapid response system.
Oliver CL, DeVita MA, Dunwoody CJ, Johnson JT, Sok JC, Simmons RL. Qual Saf Health Care. 2009;18:496-499.

The rapid response system effectively identified and managed clinical adverse events on an otolaryngology inpatient service and also identified areas for quality improvement.

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Qual Saf Health Care 2009;18:496-499 doi:10.1136/qshc.2007.024810
Error management
Patient safety on the otolaryngology service: the role of an established rapid response system
C L Oliver1, M A DeVita2, C J Dunwoody3, J T Johnson3, J C Sok3, R L Simmons3
+ Author Affiliations

1University of Pittsburgh Medical Center, Eye and Ear Institute, Pittsburgh, PA Pittsburgh, Pennsylvania, USA
2University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, Pennsylvania, USA
3University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Correspondence to
Dr Christopher L Oliver, Head and Neck Surgical Specialists, 799 E. Hampden Ave. Suite 530, Englewood, CO 80113, USA; christopher.oliver@healthonecares.com
Accepted 13 October 2008
Abstract
Objective: To study the medical emergencies occurring on a tertiary otolaryngology service identified using a rapid response system (RRS).

Design: Retrospective chart review of RRS activations during 21 months.

Setting: Specialised otolaryngology care unit within the University of Pittsburgh Medical Center Presbyterian/Montefiore Hospital, a tertiary, academic, teaching hospital in the USA.

Intervention(s): None.

Results: 1171 unit admissions. Unit mortality was 5.1/1000 admissions. 53 patients were involved in 67 RRS activations (4/53 deaths). 32 of 67 events were due to respiratory derangements, most commonly pneumonia. 18 of 67 events were due to cardiovascular abnormalities, most commonly hypertension and myocardial infarction. 11 of 67 events were secondary to mental status changes, several of which were related to adverse drug events. 6 of 67 events were secondary to acute bleeding. 23 of 67 events occurred within 24 h of patient transfer/admission, 14 of those after operations. RRS activation was a marker for in-hospital death (RR 42.2, 95% CI 7.9 to 225.2) compared with that in patients not activating the RRS.

Conclusions: Although otolaryngology care units attempt to prevent adverse events, emergencies still occur. RRSs identify deteriorating otolaryngology patients who are at increased risk for mortality. RRSs are an efficient mechanism of intervention during a medical emergency. RRSs provide a convenient method of identifying medical/system errors and educational opportunities.