Failure to Rescue Learning Laboratory

The Department of Anesthesiology has been involved in systems level research focused on critical patient safety issues for over a decade. One particular area of interest has been on Failure to Rescue (FTR), defined as the inability to prevent death after the development of a complication in the inpatient setting, a leading driver of inpatient mortality.

In recognition of the need to address FTR, we have established the Patient Safety Learning Laboratory, supported by the Agency for Healthcare Quality and Research. The Laboratory brings together multidisciplinary teams (including engineers, clinicians, and data analysts) to analyze, redesign, implement, and test early detection and rescue systems.

Our current research is organized into three general areas:

  • Technology based interventions, such as surveillance monitoring
  • Team and individual behaviors, such as hand-overs and patient assessment
  • Systems integration where we address socio-technical issues related to rescue systems

Our research methods include:

  • Evidence-based gap analysis of causes of FTR
  • Systems-level intervention design
  • Rapid prototyping and measurement of solutions
  • Full-scale integration and implementation

Our recent efforts have resulted in the successful implementation of:

  • Surveillance monitoring in general care units
  • Device integration and mobile continuous patient monitoring
  • EMR-based patient state alerts
  • Communication and shared mental model training
  • Simulation-based response training

Opportunities for further research include systems to improve clinician understanding of patient state, tools for patient placement and rescue activation, and additional training programs focused on hand-overs and patient state assessment.

Failure to Rescue Learning Lab Core Team

  • George T. Blike, MD, MHCDS (PI)
  • Amir Ghaferi, MD (Co-I UMich)
  • Joseph Hunter (Program Manager)
  • Ken Lee
  • Krystal McGovern, RN, MSN
  • Dennis McGrath, MA (Co-I)
  • Sue McGrath, PhD (Co-I)
  • Todd McKenzie, PhD
  • Irina Perreard, PhD
  • Nikita Shah, MPH (UMich)
  • Kathleen Stewart
  • Emily Wells, MPH (UMich)