Introduction
Failure to rescue (FTR) is a crucial yet often overlooked concept in nursing education. It goes beyond simply recognizing patient deterioration; it involves equipping nurses to identify early changes, understand their significance, and act promptly to prevent harm.
Although this concept has been discussed in literature for decades, its importance has only increased. Patients today are more complex, hospital stays are shorter, and new nurses are expected to handle higher acuity situations earlier in their careers.
The focus is no longer on whether we should teach failure to rescue. Instead, we need to consider: Are we teaching it effectively to prepare students for real-world practice?
The Gap Between Data and Action
Failure to rescue occurs when a patient experiences a preventable decline because early warning signs were missed, misinterpreted, or not acted upon in time.
We now understand more clearly that most patients do not deteriorate suddenly; instead, they exhibit predictable and measurable changes hours before critical events. This insight has led to the widespread adoption of:
- Early Warning Scores (EWS/MEWS/NEWS)
- Rapid response systems
- Sepsis screening protocols
These systems are based on a simple truth: deterioration leaves clues.
However, even with these systems in place, failures to rescue continue to happen. This is because recognizing a number is not the same as understanding what it means or knowing what actions to take next.
What Has Become Clear Over Time
Recent evidence continues to highlight the following key points:
- Clinical deterioration is often overlooked due to gaps in clinical judgment, rather than a lack of data.
- Trends in respiratory rate and heart rate are among the earliest indicators of patient decline.
- Delays in communication and escalation of care are still common.
- New nurses often struggle primarily with prioritization and decision-making, rather than task completion.
This reinforces a crucial point: The issue is not access to information; it is the ability to recognize patterns and take appropriate action.
The “Slow Fade” — Recognizing the Pattern
Most patients exhibit signs of deterioration between 6 to 24 hours before a critical event occurs. However, these signs rarely manifest as a single dramatic abnormal value. Instead, they reveal themselves as a trend:
- An increasing respiratory rate
- A steadily rising heart rate
- A gradual decline in blood pressure
- A patient who “just seems different”
It’s essential for students to learn to recognize patterns as they unfold over time. This requires focusing not only on whether a vital sign is abnormal but also on:
- What trends are emerging?
- How does this compare to the patient’s baseline?
- What could these changes signify physiologically?
Respiratory Rate and Heart Rate: Important Early Indicators
Respiratory rate is one of the earliest and most sensitive indicators of patient deterioration. However, it should not be viewed in isolation. An increased and trending heart rate is equally significant.
When both of these changes occur together, they often indicate:
- Early sepsis
- Hypovolemia
- Pain or stress response
- Compensation for underlying instability
Individually, these signs may be easily explained. However, when they trend together over time, they tell a more comprehensive story.
Teaching students to recognize this narrative is the foundation of clinical reasoning.
Is Failure to Rescue Truly Embedded in the Curriculum?
The concept of failure to rescue may be discussed in many programs, but discussion alone is insufficient. Students need to practice recognizing deterioration in real-world contexts—not just memorizing signs and symptoms.
This is crucial because real patients do not present as multiple-choice questions; they come with ambiguity, competing priorities, and incomplete information.
Clinical Red Flags: Understanding the Why
Foundational red flags still include:
- Respiratory changes
- Heart rate changes
- Blood pressure trends
- Temperature abnormalities
- Altered mental status
However, what matters most is helping students understand the reasons behind these changes. For example:
- Tachypnea may reflect compensation for metabolic acidosis.
- Tachycardia may signal early hypoperfusion.
Without a solid grasp of the underlying physiology, students may only see the numbers and miss their significance.
My Story
I was working as a rapid response nurse when a call came in at 3:00 a.m. Upon entering the room, I found a patient experiencing a massive gastrointestinal bleed. The patient had a large bloody stool and a systolic blood pressure in the 70s.
The patient had recently been started on warfarin due to atrial fibrillation that developed after open-heart surgery. Within five minutes, the patient coded. Despite over an hour of aggressive resuscitation efforts, the patient was ultimately placed in a body bag and taken to the morgue.
As the rapid response nurse, I carefully reviewed the chart and noticed a concerning trend: the patient’s heart rate had steadily increased over the last 12 hours from the 80s to the 120s, and the respiratory rate had consistently been over 20 breaths per minute. Unfortunately, the nurse failed to recognize these signs until it was too late.
To better prepare students, we can intentionally shift our teaching methods:
- Teach trends rather than isolated values.
- Emphasize both respiratory rate and heart rate patterns.
- Use early warning tools within learning scenarios.
- Create opportunities for students to interpret evolving data.
One effective approach is to use open-ended, unfolding case studies. Instead of selecting predetermined answers, students are encouraged to:
- Write down their observations.
- Identify concerning trends.
- Explain their interpretation of what is happening.
- Decide on the actions they would take next.
This style of learning helps uncover students’ thought processes in ways that multiple-choice questions cannot. It provides a space for them to practice the type of reasoning required in real patient care.
Failure to rescue is not merely about missing a vital sign; it is about failing to notice, then interpret the pattern. Pattern recognition is a skill that students must practice, not memorize.
- Where in your curriculum do students practice identifying trends over time
- How often are they asked to articulate their observations in their own words
- Are students practicing decision-making, or are they primarily selecting answers?
Closing Thoughts
All vital signs are vital. However, when it comes to early recognition of potential problems, two vital signs stand out when monitored together: respiratory rate and heart rate.
They are not necessarily more important on their own, but they often change before other signs, providing early indicators of what may be happening.
When students learn to recognize this pattern, they begin to think differently about patient care. This shift in thinking leads to changes in practice.
Failure to rescue patients is rarely due to a single overlooked number; rather, it results from failing to see what is unfolding and failing to act in time.
If we can ensure that every graduate is equipped to carry these foundational problem-recognition skills into their practice, we will be taking a necessary step to bridge the ongoing academic-practice gap, leading not only to improved patient outcomes but also to saving lives.
Recommended Resources
Free KeithRN Sepsis Case Study + Answer Key
Prepare your students for real-world clinical practice with an authentic, ready-to-use unfolding case study that builds clinical judgment using open-ended questions. Download now.
References
Makary, M.A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353.
Ju, T., Al-Mashat, M., Rivas, L., & Sarani, B. (2017). Sepsis rapid response teams. Critical Care Clinics, 34, 253–258.
Keith Rischer – Ph.D., RN, CCRN, CEN
As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…
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