​Many facilities rely on the Modified Early Warning Score (MEWS), a simple physiological assessment that helps identify a patient’s risk for clinical deterioration and mortality. However, one day a nurse at a hospital noticed that her patient’s MEWS score did not accurately reflect their actual risk for sepsis, a life-threatening condition in which the body’s immune system begins attacking its own tissues and organs—the patient had an elevated white blood count and an extremely elevated lactate level, which MEWS was not capturing. 

She notified her clinical charge nurse and clinical nurse specialist (CNS), and the CNS verified the error in MEWS. Nursing staff notified other critical care nurses throughout the hospital and filed a trouble ticket for the electronic health record system, which revealed that there was a systemwide issue with the build of MEWS. While this was resolved, the critical care team came to the unit to assess the patient based on their lab values for the possibility of sepsis. This nurse’s attention to detail and questioning of a potential problem with MEWS scoring not only helped protect her patient, but also prevented harm to other patients throughout the health system.​