Failure to Rescue (FTR) Learning Laboratory

From 2015 to 2020, team members were part of the Failure to Rescue Learning Laboratory, funded by the Agency for Healthcare Research and Quality (AHRQ). Much of our current work is based on findings of our in-depth analysis and design work, such as the rescue event mitigation system below.

Event mitigation system design

SAC Event Mitigation System Design
Figure: The Information Systems Infrastructure design depicts core information system components and illustrates data types and flow. Application concepts for system and patient-level applications are shown, with primary workflows identified for each platform. Source: Product images used with permission (Masimo, Inc., Irvine, CA).

REASON architecture

The Risk Evaluation And State Observation Notification (REASON) system concept was developed to enhance deterioration detection at the bedside and improve situational awareness for geographically dispersed care team members such as:

  • Providers.
  • Therapists.
  • Rapid response team members.

It provides access to patient information and explores the use of aggregated patient physiology (for example, continuous data and alarms) and state information (for example, National Early Warning System (NEWS)) as input for resource allocation, patient placement and rescue activation.

SAC REASON architecture

Characterizing rescue performance in a tertiary care medical center: a systems approach to provide management decision support. McGrath SP, MacKenzie T, Perreard I, Blike G.
BMC Health Serv Res. 2021 Aug 20;21(1):843. doi: 10.1186/s12913-021-06855-w

A Systems Approach to Design and Implementation of Patient Assessment Tools in the Inpatient Setting.
McGrath SP, Perreard I, Ramos J, McGovern KM, MacKenzie T, Blike G.Adv Health Care Manag. 2019 Oct 24;18. doi: 10.1108/S1474-823120190000018012.PMID: 32077656