7 Risk Reduction and Early Deterioration

Preventing Avoidable Harm

Preventing avoidable harm requires both thoughtful precautions and reliable surveillance. Match prevention measures to the patient’s risks, then reassess them whenever mobility, cognition, treatment, condition, or care setting changes.

Examples of individualized prevention include:

• Falls and injury: Assess mobility, balance, cognition, medications, and toileting needs. Keep needed items within reach, use appropriate footwear, and assist with transfers and walking.

• Pressure injury: Inspect skin and device-contact areas, reduce prolonged pressure, support mobility, and keep skin clean and appropriately dry. Report new discoloration, warmth, pain, or skin breakdown.

• Infection: Apply Standard Precautions. Use invasive devices only when indicated, maintain them with aseptic technique, and prompt review of their continued need.

• Medication and treatment harm: Complete required identification and medication-safety checks. Review allergies, high-risk medicines, and monitoring needs; promptly report discrepancies and unexpected effects.

• Immobility and respiratory complications: Encourage safe activity and positioning, assess breathing and pain, and follow indicated aspiration and perioperative or postoperative precautions.

• Communication failures: Share current risks, changes, pending tests, and escalation plans during handoffs. Communicate critical results promptly through facility procedures.

The central principle is to tailor precautions to the patient rather than relying on a risk label alone.

Surveillance and Recognizing Change

Surveillance starts by establishing the patient’s Baseline and comparing each new assessment with it. Follow the monitoring frequency required by the patient’s acuity, orders, and local policy. Trends and combinations of findings can be more informative than an isolated number.

Monitor relevant changes in:

• Breathing, respiratory rate, oxygen saturation, and oxygen requirement.

• Heart rate, blood pressure, temperature, perfusion, and skin appearance.

• Alertness, behavior, orientation, and new weakness.

• Pain, urine output, fluid balance, and ability to eat, drink, or move as expected.

• Laboratory and diagnostic results, especially changes from prior results and critical values.

• Wounds, skin, lines, drains, and other devices; verify that monitoring equipment functions and alarms are appropriately set.

Validated early-warning scores can help identify risk, but they supplement—not replace—clinical judgment and direct reassessment. A low score or a single apparently acceptable vital sign does not rule out a serious change. Take the patient’s or family’s concern seriously, and follow facility-defined warning signs and response procedures.

Takeaway: Compare current findings with the patient’s usual condition, look for worsening trends, and respond to concern even when a score is not high.

Warning Signs of Deterioration

Act promptly when a patient has a concerning new change, a worsening trend, or an appearance that does not fit the recorded observations. Warning signs can include increasing difficulty breathing, falling oxygen saturation, rising oxygen needs, new hypotension, marked heart-rate change, weak pulses, cool or clammy skin, confusion, reduced alertness, fainting, difficulty waking, reduced urine output, sudden functional decline, or severe and rapidly worsening pain.

Possible infection accompanied by systemic change also demands attention. Sepsis is a medical emergency. Signs may include fever or feeling very cold, clammy skin, confusion, shortness of breath, extreme discomfort, and a high heart rate or weak pulse. Do not wait for every sign to appear.

For example, a postoperative patient who becomes newly confused, breathes faster than earlier, and needs more oxygen has a concerning combination of changes. Reassess and escalate rather than treating each finding as unrelated or waiting for a score to cross a threshold.

Takeaway: A worsening pattern or persistent concern is a reason to act, even if some individual observations appear acceptable.

Escalation and Clear Communication

When deterioration is suspected, follow facility protocols and act within your role and training:

1. Stay with the patient and reassess promptly. Check airway, breathing, circulation, mental status, and vital signs. Confirm an unexpected reading when safe, but do not delay help.

2. Call for assistance early. Notify the responsible clinician and activate the rapid-response system or emergency response when criteria are met or serious concern persists. Do not wait for a score or permission when immediate help is needed. If the patient is unresponsive or not breathing normally, activate emergency response and begin actions within your training and local protocol.

3. Support immediate safety. Check that monitoring and oxygen delivery are functioning, position the patient as appropriate, reduce immediate hazards, and prepare relevant records, medication information, and recent results.

4. Communicate clearly with SBAR. State the Situation—what changed; the Background—relevant history and baseline; the Assessment—current findings and concern; and the Recommendation/Request—what action or help is needed and when. Confirm the response and plan.

5. Reassess, document, and hand off. Record the change, observations, notifications, actions, response, and follow-up. Continue monitoring at the directed frequency and escalate again if the patient does not improve or worsens.

A reliable response combines immediate reassessment, early escalation, clear communication, and follow-through. Prevention and surveillance work best when risks and changes are shared clearly across the care team.

• Risk reduction