Patient mortality and the neglect of vital signs' assessment: An audit of a national coronial database.
assessment
audit
mortality
neglect
vital signs
Journal
Nursing in critical care
ISSN: 1478-5153
Titre abrégé: Nurs Crit Care
Pays: England
ID NLM: 9808649
Informations de publication
Date de publication:
08 Feb 2024
08 Feb 2024
Historique:
revised:
10
01
2024
received:
13
03
2023
accepted:
15
01
2024
medline:
8
2
2024
pubmed:
8
2
2024
entrez:
8
2
2024
Statut:
aheadofprint
Résumé
Vital signs assessment is critical for patient surveillance and safety. Research has found, however, that this assessment is often neglected in clinical practice. The reasons for this are unclear as few studies have explored this issue. Those studies that have are small, single site studies and found that culture and poor understanding are contributing factors. The aim was to explore the link between the clinical neglect of vital signs assessment and patient mortality and provide a better understanding of factors influencing vital signs assessment in the context of acute patient care. Coroners' reports represent an untapped source of information regarding shortfalls in vital signs assessment. Using a framework analysis, an audit was conducted of the Australian National Coronial Information System for cases where vital signs' assessment was mentioned in coronial reports. Fifty-eight cases met the eligibility criteria, with deceased patients aged from 7 days to 93 years. Key themes related to absence of reassessment of vital signs, inappropriate delegation, passing responsibility to another staff member and not following policy. The findings reflect a combination of individual and institutional failings and suggest that vital signs assessment was not considered a priority aspect of care. Vital signs assessment must be considered an essential aspect of clinical care in all patients. This important aspect of care should be emphasized across all domains of patient care.
Sections du résumé
BACKGROUND
BACKGROUND
Vital signs assessment is critical for patient surveillance and safety. Research has found, however, that this assessment is often neglected in clinical practice. The reasons for this are unclear as few studies have explored this issue. Those studies that have are small, single site studies and found that culture and poor understanding are contributing factors.
AIM
OBJECTIVE
The aim was to explore the link between the clinical neglect of vital signs assessment and patient mortality and provide a better understanding of factors influencing vital signs assessment in the context of acute patient care. Coroners' reports represent an untapped source of information regarding shortfalls in vital signs assessment. Using a framework analysis, an audit was conducted of the Australian National Coronial Information System for cases where vital signs' assessment was mentioned in coronial reports.
RESULTS
RESULTS
Fifty-eight cases met the eligibility criteria, with deceased patients aged from 7 days to 93 years. Key themes related to absence of reassessment of vital signs, inappropriate delegation, passing responsibility to another staff member and not following policy.
CONCLUSIONS
CONCLUSIONS
The findings reflect a combination of individual and institutional failings and suggest that vital signs assessment was not considered a priority aspect of care.
RELEVANCE TO CLINICAL PRACTICE
CONCLUSIONS
Vital signs assessment must be considered an essential aspect of clinical care in all patients. This important aspect of care should be emphasized across all domains of patient care.
Types de publication
Journal Article
Langues
eng
Subventions
Organisme : Nurses Board of Victoria
Informations de copyright
© 2024 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.
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