Failure to Rescure-Patient Safety Learning Lab (FTR-PSLL)



 DESCRIPTION (provided by applicant): Despite over a decade of safety work in healthcare, injury and death due to preventable events remain the third leading cause of death in the U.S. [1] Wide variation in mortality rates across hospitals suggest substantial opportunities for improvement. Several decades of patient safety work have been focused on preventing complications in an effort to ultimately reduce mortality. However, these efforts have not had a significant impact and there is growing recognition that high mortality and low mortality hospitals are distinguished less by their complication rates than by how successfully they recognize and manage complications once they occur during the early period of clinical deterioration. Thus, minimizing "failure to rescue" (i.e., death following a major complication) FTR) is critical to reducing mortality in hospitalized patients. Successful rescue hinges on early recognition and timely management of serious complications once they occur, which requires understanding all of the factors involved and which are most important. We propose to establish a FTR Patient Safety Learning Lab that is focused on creating the ideal hospital rescue system. The focus will be on early "upstream" recognition and management of non-preventable complications. Studies will target gaps in understanding the technology factors behind ideal risk assessment/surveillance supporting early detection of complications and the human factor that support the ideal individual and team response in effectively managing these complications. A novel translation approach will be used to rapidly support reliable "early" rescue. Ultimately, the ideal Integrated Rescue System will have tremendous potential to reduce both the mortality and harm currently associated with FTR.