Lessons Learned at the MHA Failure-to-Rescue Safe Table Event

In partnership with the MHA Keystone Center, MHC hosted a Safe Table event for MHA member hospitals on failure-to-rescue in November.

• Safe Table is shared learning among healthcare peers to exchange patient safety experiences, discuss best practices, and learn in an open, uninhibited environment.

• Failure-to-rescue is the failure to prevent a clinically important deterioration from a complication of an underlying illness or a complication of medical care by not appropriately responding to early signs of patient deterioration.

Failure-to-rescue (FTR) lessons learned at this Safe Table event were:

• Although not every complication of medical care is preventable, health care systems should be able to rapidly identify and treat complications when they occur. 

• A study of Michigan hospitals found FTR rates range from 15.2% to 46.6%, representing a large area of opportunity to advance safety and quality.

Root causes of FTR are failure to:

1. Recognize complications early,
2. Relay information regarding the complications to the care team,
3. Work as team in addressing complications, and
4. React in a timely and appropriate manner to the patient’s deterioration.

Best practices to prevent FTR:

• Early activation of Medical Response Teams followed by establishing a clear plan that is agreed upon by all responders.
• Getting the patient to the right bed with the right resources.