Escalation Failures: Understanding and Preventing Harm in Clinical Practice

Why this topic matters

Escalation failures can manifest in many forms: a deteriorating patient not being reviewed by the correct senior clinician in a timely manner, critical information not being conveyed during a handover, or a junior clinician feeling unable to challenge a decision. The consequences can be severe, ranging from delayed diagnosis and treatment to serious adverse events, increased length of hospital stay, and even avoidable mortality. National reports, such as those from NCEPOD (National Confidential Enquiry into Patient Outcome and Death) and various serious incident investigations, frequently highlight poor escalation as a contributing factor to critical incidents.

Beyond direct patient harm, escalation failures contribute to stress and burnout among staff, particularly junior doctors and nurses who may feel unsupported or overwhelmed. Improving escalation processes is not just about compliance; it's about fostering a culture of safety, mutual respect, and effective teamwork, which ultimately benefits both patients and staff.

Practical explanation: What constitutes an escalation failure?

An escalation failure occurs when there is a breakdown in the process of conveying clinical concern or a need for higher-level intervention or decision-making. This can happen at various points in the patient journey and involves several contributing factors. It's not always about 'who' failed, but 'what' in the system allowed the failure to occur.

Common scenarios include:

• Delay in recognising deterioration: Staff not identifying signs of patient deterioration early enough, or misinterpreting them.
• Reluctance to escalate: Junior staff feeling inhibited from escalating, due to fear of appearing incompetent, perceived reprisal, or a culture that discourages questioning senior decisions.
• Ineffective communication: Concerns being communicated poorly, ambiguously, or incompletely, leading to misunderstanding or lack of urgency.
• Inadequate response to escalation: Senior staff not responding appropriately, dismissing concerns, or providing advice that is not followed or is insufficient.
• Systemic issues: Lack of clear escalation pathways, inadequate staffing levels, excessive workload, or poor handover processes.
• Lack of follow-up: Escalated concerns are addressed, but no system exists to ensure the advice was followed or the patient's condition improved.

It's crucial to distinguish between a 'failure to escalate' and an 'escalation failure'. A failure to escalate specifically points to an individual not initiating the escalation process. An escalation failure, however, implies a broader systemic breakdown, where even if an individual attempted to escalate, the process itself was flawed, leading to a poor outcome.

Contributing factors

Escalation failures rarely have a single cause. They typically arise from a complex interplay of:

1. Individual factors: Lack of experience, fatigue, cognitive biases, or communication skills.
2. Team factors: Poor teamwork, unclear roles and responsibilities, hierarchical barriers, or a culture of blame.
3. Organisational factors: Inadequate staffing, excessive workload, lack of training, poorly defined policies, or insufficient resources (e.g., bed capacity).
4. Environmental factors: High-pressure situations, noisy environments, or lack of access to patient information systems.

Common pitfalls

• Ambiguous communication: Using vague language (e.g., "patient not quite right") instead of structured communication tools like SBAR (Situation, Background, Assessment, Recommendation).
• Lack of closed-loop communication: Not confirming that the message has been received and understood, or that the required action will be taken.
• 'Halo effect' or 'authority gradient': Junior staff feeling intimidated by, or overly deferential to, senior colleagues, which prevents them from voicing concerns assertively.
• Normalisation of deviance: Gradually accepting suboptimal practices (e.g., delays in reviewing sick patients) as 'the norm' because they haven't led to harm yet.
• Over-reliance on written notes: Not following up critical or urgent information with a direct verbal escalation.
• Ignoring 'gut feelings': Dismissing clinical intuition, particularly in experienced nurses or doctors, when objective signs are not yet overtly critical.

Step-by-step approach: Preventing escalation failures

Preventing escalation failures requires a multi-pronged approach focusing on individual skills, team dynamics, and robust systems.

1. Recognise and act early

• Early warning scores (EWS): Ensure consistent and accurate use of NEWS2 (National Early Warning Score 2) and follow the associated escalation protocol. Understand that a 'normal' NEWS2 doesn't always mean a patient is stable, especially in patients with chronic conditions or atypical presentations.
• Clinical vigilance: Trust your instincts. If a patient 'doesn't look right', even without significant objective signs, initiate further assessment and consider escalation.
• Competence and confidence: Ensure all staff, particularly junior clinicians, are competent in recognising deterioration and confident in initiating the escalation process. This comes with training, supervision, and a supportive environment.

2. Communicate effectively

• Structured communication: Utilise tools such as SBAR (Situation, Background, Assessment, Recommendation) for all verbal escalations and handovers. This forces clarity and prioritisation of information.
  • Situation: Briefly state what is happening right now.
  • Background: Provide relevant clinical history, investigations, and treatments.
  • Assessment: Give your clinical impression of the problem and its severity.
  • Recommendation: Clearly state what you need from the recipient (e.g., review, advice, specific intervention, transfer).
• Closed-loop communication: Always check for understanding and confirm agreed actions. For example, the person receiving the escalation should summarise what they have heard and what they plan to do, and the person escalating should confirm this is correct.
• Professional assertiveness: Junior staff should be empowered to escalate clearly and persistently (while remaining professional) if they feel their concerns are not being adequately addressed. Senior staff have a responsibility to listen and respond respectfully.

3. Establish clear pathways and expectations

• Local escalation policies: Ensure these are clearly defined, accessible, and regularly reviewed. They should specify thresholds for escalation, who to escalate to, and expected response times.
• Role clarity: All staff should understand their roles and responsibilities in the escalation process.
• Supervisory support: Consultants and senior clinicians must create an environment where junior staff feel safe to escalate concerns without fear of criticism.
• Handover quality: Implement robust, structured handover processes (e.g., using I-SBAR or similar tools) that ensure continuity of care and effective communication of risks and escalation plans.

4. Foster a just culture

• Psychological safety: Promote an environment where staff feel safe to speak up about concerns, errors, or near misses without fear of blame. This allows for learning and system improvement.
• Learning from incidents: Treat escalation failures not as individual failings, but as opportunities to learn about systemic weaknesses. Conduct thorough root cause analyses without assigning blame.
• Feedback and debriefing: Regular debriefs after critical incidents or complex cases can provide valuable learning opportunities regarding escalation effectiveness.

Example in clinical practice

A 78-year-old patient is admitted to an acute medical ward with sepsis from a urinary tract infection. On the night shift, the staff nurse notes the patient’s NEWS2 score has risen from 3 to 6 over two hours, now including a new oxygen requirement and a falling blood pressure. The nurse pages the foundation year 1 (FY1) doctor on call, stating, “Mr. Smith in bed 4 isn't very well, his NEWS is 6.”

The FY1, busy with a cardiac arrest call, briefly advises, “Check fluids and re-page me if he gets worse.” The nurse administers fluids but feels uneasy, noticing the patient is becoming more drowsy. She remembers training on SBAR and decides to call the registrar directly.

Using SBAR:

• Situation: "Dr. Jones, I'm calling about Mr. Smith in bed 4. His NEWS2 is 6, requiring 2L oxygen, and his BP is dropping. I'm concerned he's deteriorating rapidly."
• Background: "He's 78, admitted this morning with urosepsis, started on antibiotics. No known allergies. Latest observations show HR 110, BP 90/50, RR 24, Sats 92% on air, now 95% on 2L oxygen. He's also more drowsy."
• Assessment: "I think he might be going into septic shock and needs urgent senior review, possibly ITU input."
• Recommendation: "Could you please come and review him urgently? I think he needs immediate medical review and consideration for high care level support."

The registrar quickly comes to review the patient, agrees with the assessment, arranges immediate arterial blood gases, requests senior review from the consultant, and considers transfer to critical care. This rapid, structured escalation averted a potentially catastrophic outcome, improving the patient's chances of recovery.

This example highlights the power of structured communication, professional assertiveness from the nurse, and a system (SBAR training) that enabled effective escalation despite initial hesitation.

How Lazomis can help

Lazomis offers several tools that can support NHS teams in understanding, monitoring, and improving their escalation processes, thereby mitigating the risk of escalation failures:

• QI Project Setup: For teams looking to systematically improve their NEWS2 compliance, handover processes, or ward-to-consultant escalation effectiveness, our guided QI project setup helps structure your improvement initiatives, define clear aims, and select appropriate outcome measures.
• Data Capture Tools: Design custom forms to audit the use of SBAR in escalations, capture details of delayed reviews, or track adherence to local escalation policies. This data can feed into your QI projects to identify specific areas for improvement.
• Dashboards and Reporting: Visualise trends in escalation effectiveness, response times, or compliance with NEWS2 protocols. Custom dashboards can help identify wards or shifts where escalation challenges are more prevalent, enabling targeted interventions.
• Learning Hub Integration: Document and share successful escalation strategies or lessons learned from incidents. This supports continuous learning and reinforces best practices across your organisation.

By providing a structured framework for data collection, analysis, and project management, Lazomis empowers teams to move beyond reactive responses to escalation failures towards proactive prevention and continuous improvement.

Key takeaways

• Escalation failures are a significant preventable cause of patient harm within the NHS, often stemming from systemic issues, not just individual error.
• Early recognition of patient deterioration is crucial; utilise NEWS2 and trust clinical intuition.
• Effective communication using structured tools like SBAR is fundamental for clear, unambiguous escalation.
• A 'just culture' promotes psychological safety, empowering all staff to escalate concerns without fear of blame.
• Clear local escalation policies, defined roles, and robust handover processes are essential system safeguards.
• Regular review of incidents and near misses provides vital learning opportunities to refine escalation pathways and prevent future harm.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.