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Escalation of Care in Surgery: A Systematic Risk Assessment to Prevent Avoidable Harm in Hospitalized Patients

Johnston, Maximilian MB BCh, MRCS*; Arora, Sonal PhD, MRCS*; Anderson, Oliver MSc, MRCS*; King, Dominic MB ChB, MRCS*,†; Behar, Nebil MSc, FRCS; Darzi, Ara MD, FRCS, FACS*,†

doi: 10.1097/SLA.0000000000000762

Objective: To systematically risk assess and analyze the escalation of care process in surgery so as to identify problems and provide recommendations for intervention.

Background: The ability to escalate care appropriately when managing deteriorating patients is a hallmark of surgical competence and safe postoperative care. Healthcare-Failure-Mode-Effects-Analysis (HFMEA) is a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended.

Methods: Forty-two hours of ethnographic observations on surgical wards in 3 London hospitals (phase 1) formed the basis of an escalation process diagram. A risk-assessment survey identified failures associated with process steps and attributed hazard scores (phase 2). Patient safety and clinical risk experts validated hazard scores through a group consensus meeting (phase 3). Hazardous failures were taken forward to multidisciplinary HFMEA where cause analysis was applied and interventions were recommended (phase 4).

Results: Observations identified 33 steps in the escalation process. The risk-assessment survey (30 surgical staff members, 100% response) and expert consensus group identified 18 hazardous failures associated with these steps. The HFMEA team identified 3 adequately controlled failures; therefore, 15 were subjected to cause analysis. Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure. Participants recommended interventions based on these findings including defined escalation protocols, human factors education, enhanced communication technology, and improved clinical supervision.

Conclusions: Failures in the escalation process amenable to intervention were systematically identified. This mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.

Supplemental Digital Content is Available in the Text.This quantitative, systematic study used Healthcare Failure Mode Effects Analysis to identify risks in the surgical escalation of care process. Participants identified communication, staffing, and hierarchical failures as root causes of a failure to escalate. Targeted interventions based on escalation protocols, educational sessions, and staff recruitment should improve patient safety.

*Centre for Patient Safety and

Centre for Health Policy, Department of Surgery and Cancer, Imperial College London; and

Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.

Reprints: Max Johnston, MB BCh, MRCS, Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, W2 1NY, UK. E-mail:

Disclosure: This study did not require formal ethical approval. It was registered and approved as a quality improvement project. Informed written consent was gained from all participants. All authors declare no conflicts of interest. Johnston, Arora, King, Anderson, and Darzi are affiliated with the Centre for Patient Safety and Service Quality ( at Imperial College, which is funded by the National Institute for Health Research, UK.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.