Provider error accounts for most monitor-related deaths in Pa.

Problems with physiologic alarm monitoring caused or precipitated 35 patient deaths in Pennsylvania healthcare facilities between June 2004 and December 2010. Of these, 31 were traced to human error. The findings were published in the latest Pennsylvania Patient Safety Advisory, a publication produced for that state’s Patient Safety Authority by the ECRI Institute and the Institute for Safe Medication Practices.

The connections came to light when analysts queried the agency’s database using the keywords alarm, monitor, ECG (or electrocardiogram), telemetry, pulse-ox and defibrillator in combination with intensive care unit or telemetry unit. Of the results, a total of 187 came up with a mention of death or a harm score signaling death.

Some 14 of the 31 staff errors involved disconnected equipment. This leading cause was followed by “Monitoring equipment during diagnostic testing” (six incidents), “Inadequate response to alarms” (six) and “Alarms silenced” (four). One was labeled “Unknown.”

Problems with telemetry monitors accounted for 28 of the death incidents, followed by ventilators (four problems), bi-level positive airway pressure machines (two) and blood pressure machine (one).

“In one event, a telemetry technician silenced the alarm of a patient with metastatic disease,” wrote report author Cynthia Lacker, RN, a senior patient-safety analyst with the agency. In another, “the floor nurse had silenced the telemetry alarm in the room and was relying solely on the telemetry technician (who was performing additional duties while watching the monitors) to relay alarm information.”

Equipment failures accounted for four deaths. Two owed to home equipment that lacked alarm capability (brought into the hospital by patients), one to a manufacturer’s default setting that caused a battery to power down and one to “possible” failure of a ventilator unit.

Lacker concluded: “Basic staff interventions (i.e., education regarding physiologic alarms, clear lines of responsibility for responding to alarms, discouraging silenced alarms) can be paired with equipment management interventions (i.e., scheduled equipment testing, replacement and battery change; alarm audibility testing; policies for alarm default limits) for maximum impact. Facilities can also monitor for alarm desensitization in both primary care staff and remote monitoring technicians.”

A brochure downloadable from the agency’s website noted that Pennsylvania is the only state to require that healthcare providers report both adverse events and near misses. All information submitted through its safety-reporting system is “confidential and non-discoverable, and the reports do not contain any patient or provider names.” The brochure said that, on average, the agency fields about 5,200 reports each week.

Click here for the agency website and here for a PDF of the latest edition of the Pennsylvania Patient Safety Advisory.