Enhancing Code Blue, Rapid Response, and Emergency Response Safety in the Veterans Health Administration: Using a...

Healthcare professionals acknowledge that medical emergencies may occur any time; however, many remain unaware of the potential for systems such as equipment to unexpectedly fail. Within healthcare organizations, a patient's condition can rapidly deteriorate, leading to decompensation and risk of mortality. Responders to code blue, rapid response, or other medical emergency responses may not be able to detect potential critical system failures during an event or be aware of actions or interventions that can be implemented to prevent these events.

The authors used a Combined Proactive Risk Assessment (CPRA) approach to investigate failure modes (FMs) within the code blue, rapid response, and medical emergency response processes. The study reviewed proactive risk assessments (PRAs) from 13 Veterans Health Administration (VHA) hospitals and reactive risk assessments (RRAs) such as patient safety reports and root cause analyses from 172 hospitals.

Analysis of the RRAs revealed 1,149 FMs. Failures occurred during initial patient evaluation (15.4%), when calling the code team (15.1%), and during the code team response to the code (13.5%). The majority of FMs occurred from disruptions to safeguards (barriers and controls) (47.6%), from equipment issues (22.5%) and from communication failures (14.5%). This study also compiled a list of actions from root cause analyses to mitigate future risks and harm.

The CPRA method provided a comprehensive risk analysis of the code blue, rapid response, and medical emergency response processes and identified potential solutions to these failures.