AIM:The aim of this review was to identify and synthesise published accounts of recognising and responding to patient deterioration in the presence of deterioration antecedents. DESIGN:The systematic review canvassed four electronic databases/search engines for studies of adult ward patients who had altered physiological parameters before developing major adverse events. SYNTHESIS METHODS:The findings were synthesised using a narrative approach. RESULTS:Clinical deterioration can be missed by nurses, even with adequate charting. Delays in recognising and responding to patient deterioration remains an international patient safety concern, and strategies to enhance recognition of patient deterioration have not achieved consistent improvements. The lack of significant and sustained improvement through targeted training suggests the problem may be rooted in human behaviour and local ward culture. Nurses play a pivotal role in recognising and responding to patient deterioration; however, patient records do not facilitate tracking of all nurse decisions and actions, and any undocumented care cannot be easily captured by auditing processes. CONCLUSION:Failure to recognise clinical deterioration was evident even with adequate charting. It is not clear if nurses do not recognise clinical deterioration because they failed to interpret the signs of deterioration or they made a conscious decision not to escalate based on their clinical judgement or they lacked attention at the time of the event. Whatever the reason, focus is warranted for nurses' decision-making after the recording of clinical deterioration signs and the role of human factors in delayed recognition, before maximum benefit of any strategy can be achieved.