Patient and relative understanding of Martha's Rule: identifying barriers to patient-activated escalation in a mature system.

Martha's Rule allows patients and families to escalate concerns about safety to Critical Care Outreach teams in real time. This service evaluation aimed to investigate understanding of patients and their families in two key settings; paediatric and adult secondary care. We undertook an opportunistic survey of 168 patients and relatives recruited at a single District General Hospital in North Wales, where patient and family activated escalation had been in place for more than two years and was widely advertised throughout the hospital and through communication in regional and national media. 93% of the interviewees were unaware of the service. Further barriers identified were confusion around terminology and the need for such a service, and fear of perceived "whistleblowing". We explored the differences found in understanding between patients and relatives on adult or paediatric wards. Our findings suggest the need for a review of strategy of the present national information campaign.