LR16 / Clinical risk management (CRM) practices on Training Courses to Improve Awareness of vital Signs

Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Education in patient safety
Early warning
Patient safety theme the SCP/clinical risk management practice is aimed at
A training course to improve occupational therapists awareness of vital signs.
Objective of the CRM practice
Vitals signs form the basis of early warning scores and are therefore potentially life-saving and could be used in all acute hospitals[5]. Although, just like any other tool they are only as good as thier users.
Acute diseases can be reversed or the effect limited if deterioration is detected early[4]. Occupational therapists are increasingly involved in discharge from acute areas including acute wards and emergency departments. During patient assessment for discharge, occupational therapists are able to observe for signs of a new complication, or one that has been overlooked. They could also identify acute deterioration and physiological changes that could make discharge unsuitable[4].
Short description of the CRM practice, including any references for further information
A training sesssion on vital signs was adapted to meet the needs of occupational therapists and their support staff[4].
Innovator of the SCP, country of origin
East Kent Hospitals University NHS Foundation Trust, UK
Involved health care staff
Occupational therapists
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
UK/acute hospital/critical care[4]
Summary of evidence for effectiveness, including references
Changes in vital signs provide early warning of acute deterioration and increased risk of mortality[1-3].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
The training session was originally for staff based at Kent & Canterbury Hospital but discussions among participants led to request by staff at other hospitals[4].
Summary of available information on feasibility, including references
Existing implementation tools, including references
Vital sign session, from the healthcare assistant development programme.
Potential for/description of patient involvement in the CRM practice, including references
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smith G, Collins CH (1998) Confidential inquiry into quality of care before admission to intensive care. BMJ 316:1853-1858

[2] Goldhill DR, McNarry AF (2004) Physiological abnormalities in early warning scores are related to mortality in adult inpatients. Br J Anaesth 92:882-884

[3] McGloin H, Adam SK, Singer M (1999) Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond 33:255-259

[4] Woodrow P (2010) Vital signs: a nurse-led education initiative for occupational therapists. Nurs Stand 24:44-48

[5] NHS Institute for Innovation and Improvement. Reducing Avoidable Mortality: Chief Executives Lead the Way. 2007. NHS Institute for Innovation and Improvement.

Any additional information on the CRM (e.g. implementation barriers and drivers)