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Failure to identify and treat physiological deterioration in hospitalised patients is a recurring theme in acute care literature. This results in increased Intensive Care Unit (ICU) admissions, length of hospital stay and mortality. There is evidence of unacceptable time-delays between significant physiological deterioration and referral to the ICU medical team. Despite advances in standardising patient care there continues to be Failure to Rescue (FTR) events. Contributing factors have been cited such as poor understanding of illness severity, lack of situational awareness from clinical staff and information barriers. Little is known about the ‘work as done’, workarounds and facilitators within escalation of care (EOC). Qualitative research has identified many contextual factors which affect FTR, but there is little human factors research that frames information exchange during the deteriorating patient’s EOC.



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