Poor observation skills are risking patients' lives

13 October 2009 | By Clare Lomas, Dave West | www.nursingtimes.net

Patients’ lives are being put at risk because of poor practice in basic patient observations, Nursing Times can reveal.

A snapshot survey completed by 830 visitors to nursingtimes.net suggests many nurses are failing to monitor vital signs.

Almost one in four of the respondents said they could recall at least one situation in the last month where staff failed to notice a patient’s condition was worsening, adversely affecting the patient.

The finding was described as “almost catastrophic” by the RCN’s adviser in acute and emergency care Alan Dobson. “All ward sisters and matrons need to really look at this and see if this situation applies to them. This could’ve been happening for a long time, but if we don’t act now the situation will get much worse,” he added.

One respondent said they could recall “at least 20” incidents where failure to effectively monitor vital signs contributed to a deterioration in a patient’s condition.

The use of early warning scores - where a patient’s vital signs are measured and then turned into a score to reflect the stability of their condition – could have helped to prevent these situations occurring.

But according to those who responded to the Nursing Times survey, one in five nurses said these systems were “rarely” or “never” used on their wards. And only 27 per cent said they always follow an agreed procedure when signs indicate a patient is deteriorating.

Mr Dobson said early warning score systems should be accepted practice in acute settings. “These systems provide a pathway of care and alert staff to changes in a patient’s condition. If they are not using EWS, they should be using something better,” he said.

Nursing Times’ survey revealed that many nurses feel the increased use of technology - for automated blood pressure recording - meant nurses were becoming too reliant on it.

Forty-two per cent said nurses would be less capable of identifying signs of deterioration in a patient’s condition without the equipment.

Despite 85 per cent of respondents saying that observation technology was used in their workplace, almost 40 per cent said that staff using this technology had received no training.

Just under half of the respondents to the survey said they are “not confident” or only “fairly confident” that staff who routinely carry out observations are able to identify significant changes that could indicate a patient’s condition is taking a turn for the worse.

Additionally, 47 per cent of those who replied to the survey said they had little confidence that those doing observations knew how to respond if signs indicated a patient’s condition was deteriorating.

“It is easy to take a blood pressure or temperature, but it is about putting this information together and coming to a judgement about a patient’s condition. This takes a high level of skill,” he said. “Relying on staff who are not adequately trained to spot sick patients could be putting patients at risk.”

The observations that are needed can depend on the patient and the setting, but even pulse, temperature, blood pressure and respirations are not being measured 100 per cent of the time.

Patient observation and the deteriorating patient is one of the central elements of a National Patient Safety Agency drive to increase engagement with nurses. A patient observation indicator is being developed, likely to set minimum standards for documentation, frequency of observation and use of an early warning score.

NPSA chief executive Martin Fletcher said patient deterioration was “high on the patient safety agenda”.

He told Nursing Times: “Simple measures can save lives, we see this consistently in the world of patient safety. We need to focus on making sure these measures are implemented and embedded into practice.”

Responding to Nursing Times’ survey a spokesman for the Department of Health said patient safety is the “highest priority” for the DH and the NHS. “Nurses must monitor their patients effectively and must make intelligent judgements about the frequency and type of observations to undertake so they can intervene early when a patient’s condition changes.”

Nurses’ observation skills are likely to come under further scrutiny over the next 12 months. When the “failure to rescue” outcome measure is introduced as part of nursing metrics, observations will be one of the first areas to be looked at.

The Prime Minster’s Commission on Nursing and Midwifery is also looking at the essentials of nursing care, including observation skills.