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Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study. BMJ Qual Saf 2022 Oct;31(10):716-724



Pubmed ID




Scopus ID

2-s2.0-85128972108 (requires institutional sign-in at Scopus site)   2 Citations


BACKGROUND: Unrecognised changes in a hospitalised patient's clinical course may lead to a preventable adverse event. Early warning systems (EWS) use patient data, such as vital signs, nursing assessments and laboratory values, to aid in the detection of early clinical deterioration. In 2018, an EWS programme was deployed at an academic hospital that consisted of a commercially available EWS algorithm and a centralised virtual nurse team to monitor alerts. Our objective was to understand the nursing perspective on the use of an EWS programme with centralised monitoring.

METHODS: We conducted and audio-recorded semistructured focus groups during nurse staff meetings on six inpatient units, stratified by alert frequency (high: >100 alerts/month; medium: 50-100 alerts/month; low: <50 alerts/month). Discussion topics included EWS programme experiences, perception of EWS programme utility and EWS programme implementation. Investigators analysed the focus group transcripts using a grounded theory approach.

RESULTS: We conducted 28 focus groups with 227 bedside nurses across all shifts. We identified six principal themes: (1) Alert timeliness, nurses reported being aware of the patient's deterioration before the EWS alert, (2) Lack of accuracy, nurses perceived most alerts as false positives, (3) Workflow interruptions caused by EWS alerts, (4) Questions of actionability of alerts, nurses were often uncertain about next steps, (5) Concerns around an underappreciation of core nursing skills via reliance on the EWS programme and (6) The opportunity cost of deploying the EWS programme.

CONCLUSION: This qualitative study of nurses demonstrates the importance of earning user trust, ensuring timeliness and outlining actionable next steps when implementing an EWS. Careful attention to user workflow is required to maximise EWS impact on improving hospital quality and patient safety.

Author List

Braun EJ, Singh S, Penlesky AC, Strong EA, Holt JM, Fletcher KE, Stadler ME, Nattinger AB, Crotty BH


Bradley H. Crotty MD Associate Professor in the Medicine department at Medical College of Wisconsin
Kathlyn E. Fletcher MD Professor in the Medicine department at Medical College of Wisconsin
Ann B. Nattinger MD, MPH Associate Provost, Professor in the Medicine department at Medical College of Wisconsin
Michael Stadler MD Associate Dean, Chief Medical Officer, Associate P in the Medical College Physicians Administration department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Clinical Deterioration
Focus Groups
Monitoring, Physiologic
Qualitative Research
Vital Signs