In our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutons” we wrote about an unfortunate case in which a patient died as the result of transposition of telemetry units with another patient. One day, right around nursing change of shift, two patients were admitted to the remote floor and telemetry was ordered on both. The nurse took two transmitters with him and hooked the patients up, then called the CCU monitoring nurse to tell her about the two patients just hooked up. About an hour later the CCU monitoring nurse called the remote floor because one of the patients was in ventricular fibrillation. A code was called and the floor staff and code team ran to the patient’s room, only to find him sitting in bed, watching TV and eating a meal. Only after several minutes of fiddling with his EKG leads and talking to the nurse in the CCU did anyone realize that the patient several rooms down the hall was really the one in ventricular fibrillation. The transmitters obviously had been transposed! (This is a variation of the “two in a box” phenomenon we talked about in the April 23, 2007 Patient Safety Tip of the Week “Predictable Errors”.) And, of course, the system was poorly designed in that it allowed the first nurse to take out two remote telemetry transmitters at the same time. We originally presented this case as an example of how a technological solution expected to enhance patient safety actually created a new unintended problem.
Now ECRI has issued a Patient Safety E-lert on the very same issue. They did not provide details of the cases in their database but did discuss contributing factors identified and made several good recommendations. They noted lack of good policies and procedures and lack of orientation and training plus communications failures as important contributory factors. They specifically noted things like change of shift, inexperienced staff, lack of familiarity with procedure, and distractions. They also note technological issues and workflow issues.
They recommend patient identification be verified each time a patient is hooked up to telemetry (and that means verification at both the patient’s end and the remote monitoring site). They stress that the telemetry receivers should incorporate a display with the patient identifiers to reconcile the telemetry transceiver with the correct patient (and to be especially cautious about patients with similar names). That patient identification needs to be done independently at the two sites to avoid confirmation bias.
To their recommendations we would reiterate that your system should also use the constraint function of preventing anyone from taking out two transceivers simultaneously. Allowing more than one at a time to be taken simply increases the probability of such transposition.
See also our April 1, 2008 Patient Safety Tip of the Week “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions” which discussed the Pennsylvania Patient Safety Authority advisory “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis”.
ECRI PSO. Patient Safety E-Alerts. Patient Identification Prevents Life-Threatening Events. Did you Double-Check the Cardiac Monitor? May 2011
Pennsylvania Patient Safety Authority. Patient Safety Advisory supplement “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis”. March 2008