Article Text

Download PDFPDF

How human factors affect escalation of care: a protocol for a qualitative evidence synthesis of studies
  1. Jody Ede1,
  2. Verity Westgate1,
  3. Tatjana Petrinic2,
  4. Julie Darbyshire1,
  5. Peter J Watkinson1
  1. 1 Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
  2. 2 Cairns Library, University of Oxford Health Care Libraries, Oxford, UK
  1. Correspondence to Jody Ede; jody.ede{at}


Introduction Failure to rescue is defined as mortality after complications during hospital care. Incidence ranges 10.9%–13.3% and several national reports such as National Confidential Enquiry into Patient Outcomes and Death and National Institute of Clinical Excellence CG 50 highlight failure to rescue as a significant problem for safe patient care.

To avoid failure to rescue events, there must be successful escalation of care. Studies indicate that human factors such as situational awareness, team working, communication and a culture promoting safety contribute to avoidance of failure to rescue events. Understanding human factors is essential to developing work systems that mitigate barriers and facilitate prompt escalation of care. This qualitative evidence synthesis will identify and synthesise what is known about the human factors that affect escalation of care.

Methods and analysis We will search MEDLINE (Ovid), EMBASE (Ovid) and CINAHL, between database inception and 2018, for studies describing human factors affecting failure to rescue and/or care escalation. A search strategy was developed by two researchers and a medical librarian. Only studies exploring in-hospital (ward) populations using qualitative data collection methods will be included. Screening will be conducted by two researchers. We are likely to undertake a thematic synthesis, using the Thomas and Harden framework. Selected studies will be assessed for quality, rigour and limitations. Two researchers will extract and thematically synthesise codes using a piloted data extraction tool to develop analytical themes.

Ethics and dissemination The qualitative evidence synthesis will use available published literature and no ethical approval is required. This synthesis will be limited by the quality of studies, rigour and reproducibility of study findings. Results will be published in a peer-reviewed journal, publicised at conferences and on social media.

PROSPERO registration number CRD42018104745.

  • failure to rescue
  • escalation of care
  • human factors
  • qualitative
  • thematic syntheisis
  • qualitative research

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from


  • Contributors PW is the guarantor. JE was responsible for the overall design of the QES. JE and VW drafted the manuscript. TP and JE developed the search strategy. PW and JD provided QES and qualitative expertise. All authors read, provided feedback and approved the final manuscript.

  • Funding This QES protocol is funded by NIHR Biomedical Research Centre, based at Oxford University Hospitals Trust, Oxford and the Department of Health and Wellcome Trust through the Health Innovation Challenge Fund. This publication presents independent research commissioned by the Health Innovation Challenge Fund (HICF-R9-524; WT-103703/Z/14/Z), a parallel funding partnership between the Department of Health and Wellcome Trust. This work was also supported by the NIHR Biomedical Research Centre, Oxford.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.