Grant S. Limitations of track and trigger systems and the National Early Warning Score. Part 3: cultural and behavioural factors.
ACTA ACUST UNITED AC 2019;
28:234-241. [PMID:
30811231 DOI:
10.12968/bjon.2019.28.4.234]
[Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article discusses the evidence in relation to preventable deaths and a reported culture of suboptimal care. It warns of the dangers of over-relying on track and trigger systems (TTS) in place of clinical judgement. The article explores cultural and behavioural factors, the effects of short staffing and inappropriate skill mix, which all increase the risk of human error. It emphasises a key message that registered nurses must reflect on the need to change their individual and team approaches to the recognition and assessment of the deteriorating patient.
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