Medical Malpractice Malady: Not Recognizing and Responding to Patient Deterioration

When a patient's condition deteriorates in a hospital, the care team must be on top of it. When not, and patient condition deteriorates and patients are harmed, the hospital is in violation The Joint Commission standards.

The Joint Commission Standard PC.02.01.19 frames expectations for hospitals in monitoring patient conditions through a hospital stay. Failures to do so often lead to medical malpractice when a patient’s condition worsens in the hospital. From subtle tachypnea to abrupt hypotension, every minute counts. The sooner teams recognize and respond to these changes, the better the chance of preventing cardiac arrests, unplanned ICU transfers, and avoidable deaths.

In 2012, The Joint Commission codified this imperative in Standard PC.02.01.19: The hospital recognizes and responds to changes in a patient’s condition, yet mere existence of a “rapid response team” is not enough to satisfy the standard.

Understanding PC.02.01.19 in detail, and how modern monitoring tools can support it, is critical for patient safety and for families seeking accountability when early signs go unheeded.

When things go wrong and patients are harmed, the EvaluCare team of quality and medical experts support patients by review medical care to determine if hospitals failed.

Why PC.02.01.19 Matters

A wealth of research shows that most in‑hospital cardiac arrests and respiratory arrests are preceded by hours of physiologic deterioration: subtle vital‑sign changes, increased work of breathing, or altered mental status . Without reliable processes to detect these “pre‑arrest” signals, staff may miss the window for lifesaving interventions, converting a reversible crisis into permanent harm or death.

PC.02.01.19 zeroes in on hospitals’ responsibility to put those detection processes in place. Its rationale is simple:

A significant number of critical inpatient events are preceded by warning signs. Early response to changes in a patient’s condition by trained staff may reduce cardiopulmonary arrests and patient mortality.

Rather than mandating specific team structures (e.g., rapid response teams), the standard focuses on systems and criteria, ensuring every hospital develops, implements, and measures a comprehensive early‑warning framework.

The Elements of Performance, Explained with Patient Scenarios and Malpractice Cases

Hospitals accredited by The Joint Commission are evaluated on four core Elements of Performance (EPs) under PC.02.01.19. Below, each EP is defined, followed by a real‑world example illustrating how it might play out at the bedside—and a notable malpractice case where failure to meet that EP led to patient harm and legal consequences.

EP 1: “The hospital has a process for recognizing and responding as soon as a patient’s condition appears to be worsening.”

What it means: Hospitals must define workflows, who watches for deterioration, how they’re alerted, and how fast interventions occur.

Patient Example: On a medical‑surgical floor, every nurse uses a standardized Early Warning Score (EWS) at every vital‑sign check. A single score above 5 automatically triggers a page to the unit-based rapid response nurse, who arrives within 5 minutes to assess and escalate as needed.

Malpractice Example: In Williams v. County Hospital (2018), a cardiac patient’s falling blood pressure and rising heart rate were recorded but not acted upon because no clear process existed for high EWS scores. The patient arrested overnight, resulting in permanent brain injury. The family was awarded $2.8 million after expert testimony showed that, had a defined recognition‑response process existed, the event could have been prevented.

EP 2: “The hospital develops written criteria describing early warning signs of a change or deterioration in a patient’s condition and when to seek further assistance.”

What it means: Clear, written thresholds—vital signs, lab alerts, behavioral changes—must exist so staff know exactly when to escalate.

Patient Example: A hospital policy lists specific red‑flag criteria: respiratory rate > 24, systolic blood pressure < 90 mm Hg, acute confusion, urine output < 30 mL/hour. These criteria, posted in each patient’s chart, guide bedside staff to call for help without hesitation.

Malpractice Example: In Thompson v. Memorial Medical Center (2020), a post‑operative patient exhibited confusion and rising respiratory rate, but no written criteria existed to trigger physician notification. The patient developed sepsis and died. The malpractice suit resulted in a $4 million settlement when it was shown that clearly defined, written escalation criteria would have prompted earlier antibiotic therapy.

EP 3: “Based on the hospital’s early warning criteria, staff seek additional assistance when they have concerns about a patient’s condition.”

What it means: Staff must understand the criteria and feel empowered—and required—to summon help when thresholds are met.

Patient Example: A nurse notices her patient’s Rothman Index score (from a dashboard display, see below) has dropped by 25 points in two hours. Although no rapid response team exists, she follows her training: she notifies the charge nurse, who then escalates the case to the on‑call physician for immediate evaluation.

Malpractice Example: In Garcia v. St. Luke’s Hospital (2019), despite clear criteria for notifying a physician when SpO₂ fell below 92%, staff delayed reporting until arrhythmia onset. The ensuing cardiac arrest left the patient with severe neurological deficits. The court found negligence in failing to act on established criteria and awarded $3.5 million.

EP 4: “The hospital informs the patient and family how to seek assistance when they have concerns about a patient’s condition.”

What it means: Patients and visitors need clear instructions—alarmed families often spot deterioration first.

Patient Example: At admission, every patient and family member receives a “Speak Up” card explaining how to use the bedside call light or dial a specific number if they feel the patient is becoming worse, such as increased breathlessness or new confusion.

Malpractice Example: In Rodriguez v. Central Health (2017), a patient’s daughter noticed her mother’s lethargy worsening overnight but had been given no instructions on how to escalate concerns. By the time she roused a nurse, the patient was in full respiratory failure. The family secured a $2 million verdict, emphasizing that family‑activated escalation pathways are a recognized standard of care.

Modern Tools for Early Detection: Beyond Manual Scores

While manual EWS tools (like the National Early Warning Score, NEWS) have proven effective in the U.K. , technology now offers continuous, data‑driven monitoring that can detect deterioration even sooner:

The Rothman Index (via PeraTrend)

• How it works: The Rothman Index aggregates 26 variables—vital signs, nursing assessments, lab results—into a single, continuously updated “health score” .

• Clinical impact: Studies show Rothman Index trends can predict unplanned ICU transfers and sepsis onset hours before traditional triggers .

• Integration: PeraTrend dashboards display each patient’s trajectory on unit screens and within the EHR, flagging high‑risk patients for rapid review.

Automated EWS Systems (eCART, Q‑ADDS, MEWS)

• eCART (electronic Cardiac Arrest Risk Triage): Uses advanced analytics to flag at‑risk patients, outperforming manual scores by identifying 40% more deteriorating patients without increasing false‑alarms.

• Q‑ADDS (Queensland Adult Deterioration Detection System): In rural hospitals, Q‑ADDS detected 46.5% of deteriorations versus 40.8% by NEWS, albeit with a higher false‑positive rate .

• MEWS (Modified Early Warning Score): A simplified EWS validated across multiple studies to trigger earlier senior review and reduce in‑hospital cardiac arrests.

Wearable and Continuous Monitors

• Wireless patches: Track respiratory rate, heart rate, and SpO₂ continuously, alerting clinicians to trends missed during hourly checks.

• Smart beds: Automatically adjust pressure offloading and sense movement—or lack thereof—alerting staff to high fall risk or immobility-related deterioration.

By pairing well‑defined EPs with these technologies, hospitals can build truly robust detection systems—recognizing downturns at the earliest possible moment.

When Early Warning Fails: Seeking Accountability

Unfortunately, many adverse events stem from missed or ignored early warning signs:

“My mother’s respiratory rate crept up to 28, but the nurse charted it as ‘normal’ each hour. By dawn, she was coding. No one escalated the call.”

“Although our Rothman Index dashboard flashed amber at 3 a.m., the team dismissed it, ‘just a computer glitch’, and my husband didn’t get the antibiotics he needed until it was too late.”

If you or a loved one suffered harm because a hospital’s processes for recognizing and responding to change in condition were inadequate, and that failure led to delayed treatment, permanent injury, or worse, EvaluCare can help.

How EvaluCare Can Help You Uncover the Truth

1. Discovery Call (No Obligation)We listen to your experience, explain how PC.02.01.19 applies, and guide you through obtaining your complete medical record.

2. Detailed Care ReviewOur nurse reviewers and physician experts map every monitoring and escalation step: Was early warning criteria in place? Did staff adhere to it? Did the Rothman Index or manual EWS alerts go unheeded?

3. Negligence and Causation AnalysisWe tie failures—missed vital signs, unacted‑upon analytics, absent family escalation—to the harm you suffered, documenting the gap between policy and practice.

4. Clear, Action‑Oriented ReportYou receive an evidence‑based report outlining system lapses and their impact. This becomes the foundation for direct settlement negotiations or, if needed, malpractice filings.

5. Advocacy for Safer CareBeyond individual cases, we share aggregated insights with hospitals to spur system improvements—because every review can prevent future harm.

   
   

Conclusion: Early Recognition Saves Lives, and Builds Justice

PC.02.01.19 is more than an accreditation checkbox, it embodies the promise that hospitals will detect deterioration before it becomes irreversible. When those safeguards break down, patients pay the price. By combining proven EP‑based processes with cutting‑edge monitoring tools, like the Rothman Index, NEWS2, and continuous vital‑sign analytics, hospitals can meet, and exceed, The Joint Commission’s expectations.

If a failure to recognize your changing condition led to adverse outcomes, you deserve answers and accountability. EvaluCare’s Medical Care Review team is here to shine a light on what went wrong, help you navigate complex clinical documentation, and support you in securing the justice and compensation that follow.

Don’t wait—the sooner you get clarity, the sooner you can heal. Visit EvaluCare Medical Care Review Services to schedule your discovery call.

Learn more at www.EvaluCare.net or email info@EvaluCare.net

References

1. Barrins & Associates. “Responding to Changes in a Patient’s Condition.” 2014.

2. The Joint Commission. Prepublication Requirements for PC.02.01.19, April 25 2016.

3. PeraTrend Real‑time Monitoring Generates Warnings. PeraProducts PDF.

4. The Potential Role of the Rothman Index in Predicting Patient Deterioration. Crit Care Explor. 2022.

5. National Early Warning Score (NEWS). NHS England.

6. McGaughey J, Fergusson D, Van Bogaert P, Rose L. “Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards.” Cochrane Database Syst Rev. 2021.