Date of Award

Fall 2021

Document Type

Dissertation - Restricted

Degree Name

Doctor of Philosophy (PhD)



First Advisor

Guttormson, Jill

Second Advisor

Schindler, Christine

Third Advisor

Rapala, Kathryn


Delayed rapid response system (RRS) activation during patient deterioration is associated with increased mortality, longer length of stay, and ICU admission, and is regarded as failure to rescue (FTR). A culture of safety (COS) may support nurses in recognition, communication, and management of patient deterioration and therefore prevent FTR. A single-site, descriptive, cross-sectional study with retrospective medical record review was used to describe COS, FTR, and COS factors that may contribute to FTR. Ninety-seven nurses from ten acute care units in a midwestern academic medical center were surveyed for perceived COS using the American Association of Critical Care Nurses Healthy Work Environment Assessment Tool, the Practice Environment Scale of the Nurse Work Index, and researcher-developed items. FTR data (time measured from first documented sign of deterioration to time of RRS activation, transfer to ICU, or cardiopulmonary arrest) was obtained for 114 patients. To explore differences in COS related to FTR, t-tests were used to compare nurses’ perceptions of COS on units with faster response to deterioration versus those on units with prolonged response times. Perceptions of professional identity were higher than mean overall COS, while perceived absence of hierarchy and shared experience were lower than mean overall COS. Time to response after the initial sign of deterioration was greater than 60 minutes for more than 81% of events reviewed. The most frequent initial sign of deterioration was nurse concern, while a respiratory rate greater than 25 had the longest time to response. Patients with a heart rate less than 40 beats per minute had the shortest time to response. Nurses on units with faster response times had higher perceptions of overall COS and shared experience. COS is a multifactorial concept that influences rescue. These results pose implications for nursing practice and healthcare systems, which include decreasing hierarchy and ensuring a shared experience and collaborative work environment. Additional research is needed to refine the concept of COS in relation to FTR, and to identify and test interventions to improve COS. FTR requires further research to improve understanding of how patients become vulnerable to FTR, even in the presence of COS.



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