To reduce in-hospital cardiac arrest and mortality rate through earlier recognition of the deteriorating patient

Research shows that failure to rescue patients whose condition is rapidly deteriorating is an area of significant unintended harm in the healthcare environment.

By reviewing a number of key areas of practice in the multi-disciplinary team significant improvements in rates of harm can be achieved.

How to reduce harm from deterioration

This intervention addresses six key areas relating to recognition and treatment of the deteriorating patient.

These are shown in the diagram above.

Our 'How to' guide for Reducing Harm from Deterioration is aimed at team members involved in implementing changes to reduce harm from deterioration.

NHS Somerset

Helen Parsons, patient safety programme manager, Janet Ashworth, associate director of nursing and patient safety, and Lucy Watson deputy director of nursing and patient safety, explain how Somerset's primary care trust is putting patient safety first.


Newham University Hospital

Newham University Hospital NHS Trust is learning a great deal from its safety journey. Since participating in the Leading Improvement in Patient Safety (LIPS) programme, run by the NHS Institute for Innovation and Improvement’s Safer Care team, the Trust has put in place a range of key building blocks to improve the safety of its patients.


Salford Royal - collaborative working

Case study

A Breakthrough Series collaborative was used to engage staff to change their clinical area, which has resulted in cardiac arrests being viewed as never events...

Read more…

South Devon Healthcare Foundation Trust

Case study

South Devon introduced a structure for presenting critical information at handover. This has aided communication between team members and benefited care... 

Read more…

Royal Devon and Exeter

Case study

It is recognised that hospitals may not consistently be the place of safety that patient expect. Indeed, some literature suggests that early recognition of deterioration can be inconsistent...

Read more…

George Eliot Hospital

Case study

Back in 2005 George Eliot Hospital Trust had one of the worst patient safety records in England. Since then it has been changing the way staff of all levels work and has greatly reduced the number of adverse events... 

Read more…

Gateshead Health Foundation Trust

Case study

Avril Lowery, Head of SafeCare, Gateshead Health Foundation Trust, tells how they have taken the guiding principle of Patient Safety First, to make patient safety everyone’s  number one priority , and applied it to their own environment creating an internal campaign that works for them...

Read more…

Heart of England Foundation Trust

Case study

Together with information gathered from the Institute of Healthcare Improvement and visits to other healthcare systems, we had many ideas about how we could improve patient safety so signing up to Patient Safety First was a natural step to support the Trust’s safety improvement programme... 

Read more…

Salford Royal NHS Foundation Trust

Installing an old-fashioned sphygmomanometer beside every hospital bed may seem at odds with 21st century quality health care.  But recalling this ‘key cornerstone in nursing provision from the past’ has already contributed to a 30 percent reduction in unexpected cardiac arrest outside critical care...

Read more…

Royal United Bath Hospital

"The organisation learned a lot from the ward where these changes and closer monitoring were first implemented"


Resources available

The 'How to' guide and summary can be downloaded from here.

Title Type Size
'How to' guide for Reducing Harm from Deterioration pdf 726kb
The Summary - Reducing Harm from Deterioration pdf 67kb
NHS Institute web page on the SBAR communication tool link n/a

Deterioration network

There is a deterioration forum for online discussions and sharing available in the community section of our website. Click here to access the forum (login required)

Click on the map below to find out which Trusts in your region are implementing the Deterioration intervention. If your Trust is implementing the Deterioration intervention and is not listed here, please contact us.

Uk Map  London South Central North East Yorkshire and Humber East Midlands East of England South East West Midlands South West North West

Register today

Share, learn, grow.

Join the Patient Safety First community website.

Read more

Already a member

Forgotten your password?

Not registered?

Interventions homepage