Colorado Hospital Evaluates Missed Opportunities in Rapid Response Teams

Results not typical from simulation training or education

Bourg's team found that the majority of missed opportunities occurred in the off-hours of the hospital: on the weekends, before 7 a.m., and after 5 p.m.

Bourg also discovered that when the nurses appropriately identified a patient in need of an RRT, there were acute changes in the patient's condition. But when the changes to the patient were not as acute and more subtle, the nurses did not notice them quite as readily.

Even though the number of missed opportunities decreased toward the end of 2008, as 2009 began, Bourg watched the numbers increase, despite staff members having gone through simulation training.

"We sat down and knew there were other issues we needed to identify because the numbers were increasing despite the fact we had provided staff members with training," says Bourg.

At first, Bourg thought it might have something to do with new graduates working at SACH. But after looking closer, Bourg discovered that other factors contributed to the missed opportunities.

"In addition to the huge changeover we saw at SACH, we also saw that staff members who had been with us for over two years were failing to activate an RRT," says Bourg.

In hopes of improving the number of missed opportunities, Bourg and her colleagues went back and began interviewing staff members who failed to activate an RRT. They developed a debriefing tool using a variety of nursing literature to help understand why nurses were failing to activate the RRT.

"We try to make sure that when a missed opportunity presents itself, we contact the nurse within 24 to 48 hours to ask them more about the situation," says Bourg.

When a nurse has a missed RRT opportunity, an advance practice nurse conducts a debriefing interview—not the manager. During the interview, the nurse is asked questions about:

• What was going on at the time of the missed opportunity


• What kind of patient report he or she received from the previous nurse


• Whether there were competing priorities


• Whether he or she was familiar with the patient's case

"We are not trying to assign any blame," says Bourg. "We are trying to create a culture of safety so people are willing to come forward and give us the information to help make our practice better." In addition, staff went through simulation training again in July 2009.

For more on this story and tips for successful RRTs, see the April issue of Briefings on Patient Safety, a product of Patient Safety Monitor.