Responding to Patient Deterioration: A Medical Records Analysis


  • Salizar Mohamed Ludin



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 doctor’s responses were analysed retrospectively.
Results: Out of 200 records obtained, only 10 patients’ medical records met the study inclusion criteria. Three main themes were evident in the study, namely ‘track and trigger’, ‘hierarchical intervening’ and ‘attitude’. 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.


1. Che HT, Ching WC, Shao JW, Chin YH, Hung TY, Hsiu LC. Comparison of risks factors for unplanned ICU transfer after ED admission in patients with infections and those without infections. The Scientific World Journal 2014; 168: 1300-1308.
2. Kerlin MP, Small DS, Cooney E, Fuchs BD, Bellini LM, Mikkelsen ME, et al. A Randomized Trial of Nighttime Physician Staffing in an Intensive Care Unit. N Engl J Med [Internet]. 2013;368(23):2201–9. Available from:
3. Long AC, Kross EK, Engelberg RA, Downey L, Nielsen EL, Back AL, et al. Quality of dying in the ICU: is it worse for patients admitted from the hospital ward compared to those admitted from the emergency department? Intensive Care Med. 2014;40(11):1688–97.
4. Ensminger SA, Morales IJ, Peters SG, Keegan MT, Finkielman JD, Lymp JF, et al. The hospital mortality of patients admitted to the ICU on weekends. Chest [Internet]. 2004;126(4):1292–8. Available from:
5. Delgado MK, Liu V, Pines JM, Kipnis P, Gardner MN, Escobar GJ. Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system. J Hosp Med. 2013;8(1):13–9.
6. Henriksen DP, Brabrand M, Lassen AT. Prognosis and risk factors for deterioration in patients admitted to a medical emergency department. Vol. 9, PLoS ONE. 2014.
7. Hravnak M, Edwards L, Clontz A, Valenta C, DeVita MA, Pinsky MR. Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. Arch Intern Med. 2008;168(12):1300–8.
8. Tsai JCH, Cheng CW, Weng SJ, Huang CY, Yen DHT, Chen HL. Comparison of risks factors for unplanned ICU transfer after ED admission in patients with infections and those without infections. Vol. 2014, The Scientific World Journal. 2014.
9. Buykx P, Cooper S, Kinsman L, Endacott R, Scholes J, McConnell-Henry T, et al. Patient deterioration simulation experiences: Impact on teaching and learning. Collegian [Internet]. 2012;19(3):125–9. Available from:
10. Simmes FM, Schoonhoven L, Mintjes J, Fikkers BG, van der Hoeven JG. Incidence of cardiac arrests and unexpected deaths in surgical patients before and after implementation of a rapid response system. Ann Intensive Care. 2012;2(1):1–12.
11. Mackintosh N, Rainey H, Sandall J. Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline. BMJ Qual Saf [Internet]. 2012;21(2):135–44. Available from:
12. Ludin SM, Basri MN, Ali,NM & Mohamad S. The needs for implementation of ICU outreach services at hospitals in East Coast Malaysia: Comparison between ICU and ward nurses' knowledge, attitude and perception. 2013; Unpublished Undergrduate Thesis.
13. Ritchie, J., & Spencer, L., Analysing qualitative data. Qualitative data analysis for applied policy research. Bryman A, Burgess RG (ed): Routledge, London, 1994, 173-94. /
14. NICE Clinical Guidelines. Acutely ill adults in hospital: recognising and responding to deterioration. 2007;(July):1–30. Available from:
15. Andrews T, Waterman H. Packaging: A grounded theory of how to report physiological deterioration effectively. J Adv Nurs. 2005;52(5):473–81.
16. Royal College of Physicians. National Early Warning Score (NEWS): Standardising the assessment of acute illness severity in the NHS. (2012). Report of a working party. London: Royal College of Physicians.
17. So SN, Ong CW, Wong LY, Chung JYM, Graham CA. Is the Modified Early Warning Score able to enhance clinical observation to detect deteriorating patients earlier in an Accident & Emergency Department? Australas Emerg Nurs J [Internet]. 2015;18(1):24–32. Available from:
18. Chandu A, Smith ACH, Rogers SN. Health-related quality of life in oral cancer: A review. J Oral Maxillofac Surg. 2006;64(3):495–502.
19. Ansell H, Meyer A, Thompson S. Facing Nursing Assessment. 2015;24(17):886–90.
20. National Institute for Health and Clinical Excellence (NICE). National Clinical Guideline No 1. Dublin: Royal College of Physicians of Ireland. 2013.
21. Lydon S, Byrne D, Offiah G, Gleeson L, O’Connor P. A mixed-methods investigation of health professionals’ perceptions of a physiological track and trigger system. BMJ Qual Saf. 2016;25(9):688–95.
22. Jones DA, DeVita MA, Bellomo R. Rapid-Response Teams. N Engl J Med [Internet]. 2011;365(2):139–46. Available from:
23. Peris A, Zagli G, MacCarrone N, Batacchi S, Cammelli R, Cecchi A, et al. The use of Modified Early Warning Score may help anesthesists in postoperative level of care selection in emergency abdominal surgery. Vol. 78, Minerva Anestesiologica. 2012. p. 1034–8.
24. Considine J, Currey J. Ensuring a proactive, evidence-based, patient safety approach to patient assessment. J Clin Nurs. 2015;24(1–2):300–7.
25. Barfod C, Lauritzen MMP, Danker JK, Soletormos G, Berlac PA, Lippert F, et al. The formation and design of “The Acute Admission Database”- a database including a prospective, observational cohort of 6279 patients triaged in the Emergency Department in a larger Danish hospital. Scand J Trauma Resusc Emerg Med. 2012;29(April):29.
26. Ram CVS. Hypertension guidelines in need of guidance. J Clin Hypertens. 2014;16(4):251–4.
27. Snyder BD, Polasek TM, Doogue MP. Drug interactions: principles and practice. Australian Prescriber. 2012; 35: 85–88.
28. Duncan EM, Francis JJ, Johnston M, Davey P, Maxwell S, McKay GA, et al. Learning curves, taking instructions, and patient safety: Using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. Implement Sci. 2012;7(1):1–13.
29. Alan S, Ozturk M, Gokyildiz S, Avcibay B, Karataş Y. An evaluation of knowledge of pharmacovigilance among nurses and midwives in Turkey. Indian J Pharmacol [Internet]. 2014;45(6):616–8. Available from:
30. Al-Dhawailie AA. Inpatient prescribing errors and pharmacist intervention at a teaching hospital in Saudi Arabia. Saudi Pharm J [Internet]. 2011;19(3):193–6. Available from:
31. Alsulami Z, Conroy S, Choonara I. Medication errors in the Middle East countries: A systematic review of the literature. Eur J Clin Pharmacol. 2013;69(4):995–1008.
32. Ludikhuize J, Smorenburg SM, de Rooij SE, de Jonge E. Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. J Crit Care [Internet]. 2012;27(4):424.e7-424.e13. Available from:
33. Seward E, Greig E, Preston S, Harris RA, Borrill Z, Wardle TD, et al. A confidential study of deaths after emergency medical admission: Issues relating to quality of care. Clin Med (Northfield Il). 2003;3(5):425–34.
34. Cameron A, Millar J, Szmidt N, Hanlon K, Cleland J. Can new doctors be prepared for practice? A review. Clin Teach. 2014;11(3):188–92.
35. Duffield C, Diers D, O’Brien-Pallas L, Aisbett C, Roche M, King M, et al. Nursing staffing, nursing workload, the work environment and patient outcomes. Appl Nurs Res [Internet]. 2011;24(4):244–55. Available from:
36. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: A prospective study. Lancet. 2002;359(9315):1373–8.
37. Razalee S. Relationship between Body Composition, Smoking and Physical Fitness of Malaysian Armed Forces Naval Trainees. Open Access Sci Reports Bergqvist [Internet]. 2012;1(11):1–5. Available from:




How to Cite

Ludin, S. M. (2018). Responding to Patient Deterioration: A Medical Records Analysis. INTERNATIONAL JOURNAL OF CARE SCHOLARS, 1(2), 22–29.