Responding to Patient Deterioration: A Medical Records Analysis
Keywords:Nurses, Junior Doctors, Deteriorating Patients, Risk Assessment, Medical Records
Objective: This paper reports the medical record analysis findings to identify nurses, and junior doctors risk assessment and response to the incidence of deteriorating patient in general ward. Methods: A medical records analysis was conducted at a medical ward in one Malaysian hospital. Patients that were admitted for more than 24 hours and scored at least 3 points on the Modified Early Warning Sign (MEWS) assessment with their last 24 hours parameters calculated and nurses and junior doctorâ€™s responses were analysed retrospectively.
Results: Out of 200 records obtained, only 10 patientsâ€™ medical records met the study inclusion criteria. Three main themes were evident in the study, namely â€˜track and triggerâ€™, â€˜hierarchical interveningâ€™ and â€˜attitudeâ€™. Conclusion: This study demonstrates that some nurses and junior doctors experience difficulties in effectively responding to patient deterioration which often occurs at a critical juncture. This study highlights factors which need to be addressed to increase patient safety and improve medical outcomes during hospitalisation.
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