Research Article| Volume 85, ISSUE 12, P1699-1703, December 2014

Download started.


Serious adverse events in a hospital using early warning score – What went wrong?



      To evaluate the performance of a new early warning score (EWS) system by reviewing all serious adverse events in our hospital over a 6-month time period.


      All incidents of unexpected death (UD), cardiac arrest (CA) and unanticipated intensive care unit admission(UICU) of adult patients on general wards were reviewed to see if the escalation protocol that is part of the EWS system was followed in the 24 h preceding the event, and if not where in the chain of events failure occurred.


      We found 77 UICU and 67 cases of the combined outcome (CO) of CA and UD. At least two full sets of EWS were recorded in 87, 94 and 75% of UICU, CA and UD. Patients were monitored according to the escalation protocol in 13, 31 and 13% of UICU, CA and UD. Nurses escalated care and contacted physicians in 64% and 60% of events of UICU and the corresponding proportions for CO were 58% and 55%. On call physicians provided adequate care in 49% of cases of UICU and 29% of cases of the CO. Senior staff was involved according to protocol in 53% and 36% of cases of UICU and CO, respectively.


      Poor compliance with the escalation protocol was commonly found when serious adverse events occurred but level of care provided by physicians was also a problem in a hospital with implemented early warning system. This information may prove useful in improving performance of EWS systems.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • DeVita M.A.
        • Bellomo R.
        • Hillmann K.
        • et al.
        Findings of the first consensus conference on medical emergency teams.
        Crit Care Med. 2006; 34: 2463-2478
        • Prytherch D.R.
        • Smith G.B.
        • Schmidt P.E.
        • et al.
        ViEWS—toward a national early warning score for detecting adult inpatient deterioration.
        Resuscitation. 2010; 81: 932-937
        • Royal College of Physicians
        National Early Warning Score (NEWS): Standardizing the assessment of acute illness severity in the NHS report of a working party.
        RCP, London2012
        • Smith G.B.
        • Prytherc D.R.
        • Meredith P.
        • et al.
        The ability of the national early warning score (NEWS) to discriminate patients at risk of early cardiac arrest, unanticipated intensive care unit admission, and death.
        Resuscitation. 2013; 84: 465-470
        • Murray A.
        • Kellet J.
        • Huang W.
        • et al.
        Trajectories of the averaged abbreviated Vitalpac ™ early warning score (AbEWS) and clinical course of 44,531 consecutive admissions for acute medical illness.
        Resuscitation. 2014; 85: 544-548
        • Kellett J.
        • Kim A.
        Validation of an abbreviated Vitalpac TM early warning score (ViEWS) in 75,419 consecutive admissions to a Canadian Regional Hospital.
        Resuscitation. 2012; 83: 297-302
        • DeVita M.A.
        • Smith G.B.
        • Adam S.K.
        • et al.
        Identifying the hospitalized patient in crisis—a consensus conference on the afferent limb of rapid response systems.
        Resuscitation. 2010; 81: 375-382
        • Adelsteine B.A.
        • Piza M.A.
        • Nayar V.
        • et al.
        Rapid response systems: a prospective study of response times.
        J Crit Care. 2011; 26 (e11-635.e18): 635
        • Trinkle R.M.
        • Flabouris A.
        Documenting rapid response system afferent limb failure and associated patient outcomes.
        Resuscitation. 2011; 82: 810-814
        • Morrison L.J.
        • Neumar R.W.
        • Zimmermann J.L.
        • et al.
        Strategies for improving survival after in-hospital arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association.
        Circulation. 2013; 127: 1538-1563
        • Nolan J.P.
        • Hazinski M.F.
        • Billi J.E.
        • et al.
        Part 1: Executive summary 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendation.
        Resuscitation. 2010; 81S: e1-e25
        • MERIT Study Investigators.
        Introduction of the medical emergency team (MET) system: a cluster-randomizsed controlled trial.
        Lancet. 2005; 365: 2091-2097
        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, Inter American Heart Foundation, Resuscitation Council of Southern Africa).
        Resuscitation. 2004; 63: 233-249
        • Boniatti M.M.
        • Azzolini N.
        • Viana M.V.
        • et al.
        Delayed medical emergency team calls and associated outcomes.
        Crit Care Med. 2014; 42: 26-30
        • Tirkkonen J.
        • Ylä-Mattila J.
        • Olkkola K.T.
        • et al.
        Factors associated with delayed activation of medical emergency team and excess mortality: an Utstein-style analysis.
        Resuscitation. 2013; 84: 173-178
        • Santamaria J.
        • Tobin A.
        • Holmes J.
        Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.
        Crit Care Med. 2010; 38: 445-450
        • Shearer B.
        • Marshall S.
        • Buist D.M.
        • et al.
        What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
        BMJ Qual Saf. 2012; 21: 569-575