Document Detail


How I nearly MET my maker: a story of clinical futile cycles and survival.
MedLine Citation:
PMID:  21226387     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
In this series, the articles have highlighted a variety of implementation methods and uses of rapid response systems (RRSs). They have described how RRSs have been uniquely tailored to the organizations' culture and clinical environments, with largely positive results following implementation. In this article, Dr. Buist tells a somewhat different story, a highly personal one, which focuses on his own critical decompensation after surgery at his own hospital. The RRS (in this case, a medical emergency team was the efferent arm) at first successfully intervened, only to make a near-tragic error. Yet, as Dr. Buist, one of the leading proponents of RRSs worldwide, argues, the RRS-like any system-has the potential to err. He reminds us that even safety nets can require safety nets. So this story is also a cautionary tale: Just because your hospital has implemented an RRS, it does not mean (1) that the system is perfect or (2) that all preventable deaths are averted. To meet the goal of eliminating all preventable deaths in hospitals, an RRS requires continuous surveillance and adjustment. Furthermore, it must be implemented and operated in the context of the hospital's organizational culture. Although the administrative and quality improvement arms of the RRS are often underemphasized, this story exemplifies their importance--not just for RRSs but indeed for all hospital systems. The author, one of the leading proponents of rapid response systems worldwide, recounts his own close-call experience, in which he found himself in what he terms a clinical futile cycle.
Authors:
Michael D Buist
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Joint Commission journal on quality and patient safety / Joint Commission Resources     Volume:  36     ISSN:  1553-7250     ISO Abbreviation:  Jt Comm J Qual Patient Saf     Publication Date:  2010 Jul 
Date Detail:
Created Date:  2011-01-13     Completed Date:  2011-01-31     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101238023     Medline TA:  Jt Comm J Qual Patient Saf     Country:  United States    
Other Details:
Languages:  eng     Pagination:  334-6     Citation Subset:  IM    
Affiliation:
Patientrack, Sydney, Australia. Michael.Buist@utas.edu.au
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MeSH Terms
Descriptor/Qualifier:
Appendectomy
Health Care Surveys
Hospital Mortality
Hospital Rapid Response Team / organization & administration*
Humans
Postoperative Care / methods
Postoperative Complications / therapy
Safety Management / organization & administration

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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