A Brief Analysis of – Related Events

Elizabeth Kukielka, PharmD, MA, RPh, Kelly R. Gipson, BSN, RN & Rebecca Jones, MBA, RN DOI: 10.33940/biomed/2019.12.4

Abstract submitted to PA-PSRS. User errors accounted for nearly half (47.1%, Successful telemetry monitoring relies on 263 of 558) of events in the analysis. The timely clinician response to potentially life- most common event subtypes included: threatening cardiac rhythm abnormalities. errors involving batteries in telemetry Breakdowns in the processes and procedures monitoring equipment (14.0%); errors associated with telemetry monitoring, as in which patients were not connected to well as improperly functioning telemetry telemetry monitoring equipment as ordered monitoring equipment, may lead to events (12.9%); errors involving broken, damaged, that compromise patient safety. An analysis or malfunctioning telemetry monitoring of reports submitted to the Pennsylvania equipment (10.9%); and errors in which Patient Safety Reporting System (PA-PSRS) patients were connected to the wrong from January 2014 through December 2018 telemetry monitoring equipment (9.0%). identified 558 events specifically involving interruptions or failures associated with Keywords: telemetry, cardiac monitoring, telemetry monitoring equipment or with the patient safety, alarm management, healthcare providers responsible for setting cardiac arrhythmias, communication, up and maintaining proper functioning of equipment malfunction, monitor technician that equipment. The analysis highlighted Corresponding author a steady increase in the quantity of Patient Safety Authority event reports associated with telemetry Disclosure: The authors declare that they have no relevant or material financial interests.

36 I PatientSafetyJ.com I December 2019 Figure 2: Telemetry Monitoring Events by Harm Score, N=558

A – Circumstances that could cause adverse events (e.g., 300 289 look-alike medications, confusing equipment, etc.) Introduction Methods B1 – An event occurred but it did not reach the individual (“near miss” or “close call”) because of chance alone B2 – An event occurred but it did not reach the individual ontinuous cardiac monitoring of a patient We queried PA-PSRS for events submitted from 250 (“near miss” or “close call”) because of active recovery outside the setting of the intensive care January 1, 2014 through December 31, 2018. We efforts by caregivers unit (ICU) is usually achieved via portable identified events for analysis if one of the free text C – An event occurred that reached the individual but telemetry monitoring equipment (hereafter fields contained either “telemetry” or “tele” (excluding 200 did not cause harm and did not require increased C monitoring (an error of omission such as a missed referred to in some instances as “equipment”) “telephone” and “telemed”) and one of the following: medication dose does reach the individual) connected to a patient that transmits vital data, such “off”, “alarm”, “batter”, “disconnect”, “expire”, or D – An event occurred that required monitoring to 150 confirm that it resulted in no harm and/or required as rate and rhythm, to a telemetry monitoring “transmi”. An analyst manually reviewed all event 118 intervention to prevent harm station that may be located on the nursing unit or reports to identify events that involved interruptions E – An event occurred that contributed to/resulted in 92 temporary harm and required treatment or intervention to a remote centralized telemetry monitoring unit or failures associated with equipment or with the 100 F – An event occurred that contributed to/resulted located away from the nursing unit.1 Successful healthcare providers responsible for setting up and in temporary harm and required initial or prolonged telemetry monitoring relies on timely clinician maintaining proper functioning of that equipment. hospitalization G – An event occurred that contributed to/resulted in response to potentially life-threatening cardiac Events related to telemetry monitoring were 50 25 permanent harm rhythm abnormalities identified through the use categorized according to whether they resulted from 18 13 H – An event occurred that resulted in a near-death event (e.g., required ICU care or other intervention necessary of this healthcare technology. Breakdowns in the user errors, communication breakdowns between 1 0 0 2 0 to sustain life processes and procedures associated with telemetry healthcare providers, device malfunctions, or alarm A B1 B2 C D E F G H I I – An event occurred that contributed to/resulted in death monitoring, as well as improperly functioning issues, and were then further subcategorized within equipment, may lead to events that compromise each of these categories. patient safety. Figure 3: Telemetry Monitoring Events by Category and Subcategory, N=558 Results Following review of several event reports submitted to the Pennsylvania Patient Safety Reporting System* The query returned 1,494 event reports submitted (PA-PSRS) involving telemetry monitoring that resulted to PA-PSRS during the five-year study period. An in serious harm, we decided to investigate the full analyst manually reviewed all events and determined spectrum of events in PA-PSRS involving interruptions that 812 events specifically involved interruptions or failures related to telemetry monitoring. In addition or failures related to telemetry monitoring. The to our analysis, we also share relevant examples of remaining 682 events were excluded from the telemetry monitoring events to promote awareness of analysis because they did not involve interruptions areas in which actionable changes within healthcare or failures related to telemetry monitoring; many of facilities are possible, as well as a summary of lessons these events simply mentioned that the patient was learned from these events. on telemetry monitoring. Of the 812 events involving interruptions or failures related to telemetry monitoring, 558 events were included in the analysis because they were related Figure 1: Number of Telemetry Monitoring Events Submitted to issues with the equipment or by200 Year, N=558 with the healthcare providers 180 responsible for setting up and 160 maintaining proper functioning 140 of that equipment (e.g., a patient 120 who became disconnected from 100 equipment during transfer from one unit to another); 254 events 80 were excluded from the analysis 60 because they were considered 40 to be outside the control of the 20 hospital staff and unrelated to 0 the function of equipment (e.g., a 2014 2015 2016 2017 2018 patient who became disconnected from telemetry following a fall). 38 I PatientSafetyJ.com I December 2019 Patient Safety I December 2019 I 39 Table: Telemetry Event Subcategories Figure 1 shows the number of events submitted each based on actual reports submitted to PA-PSRS, but S ubcategory Definition year from 2014 through 2018. The majority (97.1%, none of these examples represents an individual Patient not connected Patient had verbal or w ritten ord ers for to telemetry event report, and event details were modified to continuous telemetry monitori ng, but 542 of 558) of telemetry monitoring events were monitoring equipment monitoring was delayed or not initiated † as ordered categorized as incidents ; the remaining 16 events ensure confidentiality. ‡ Patient had orders for continuous telemetry were categorized as serious events . Harm scores Patient transferred or Equipment Malfunctions Harm associated“ with monitoring, but patient was transferred transported without were identified by healthcare facilities at the time of from one unit to another unit without telemetry monitoring their reporting. Figure 2 summarizes the frequency Telemetry Monitoring Equipment Broken, proper monitoring d uring transit telemetry monitoring is rare of each harm score and includes definitions of each Damaged, or Malfunctioning Patient had orders for continuous telemetry but potentially catastraphic, Patient off unit harm score. Most serious events (harm scores E–I) monitoring but was not properly monitored The telemetry monitoring technician called to without telemetry while off the unit (such as while receiving resulted in death (13 of 16). monitoring notify the nurse on the medical/surgical unit that with death being the most dialysis or imaging) GP’s cardiac tracing had not been displayed on the Telemetry monitoring events were categorized frequent outcome among technician’s central monitor for about 10 minutes, Patient had orders for continuous telemetry according to whether events resulted from user errors, monitoring but was permitted to be off the and that he was now displaying in serious events. Patient not unit without telemetry monitoring for a communication breakdowns between healthcare reconnected to with a rapid ventricular rate. The nurse attempted to procedure or test; however, upon return to telemetry monitoring providers, device malfunctions, or alarm issues. User the unit, the patient was not reconnected to rectify the situation by changing the leads connected equipment upon errors accounted for nearly half (47.1%, 263 of 558) the telemetry monitoring equipment in a return to unit to the patient as well as the batteries in the telemetry timely fashion and was therefo re of the events. Events were further subcategorized transmitter, but GP yet again did not display on the unmonitored for some period of time based on common details among reports, and these technician’s central monitor. A biomedical technician categories are defined in the Table. The distribution Patient was connected to telemetry tested the equipment and identified an equipment User Errors of each event category and subcategory is summarized monitori ng equipment under the wrong failure. They replaced the telemetry transmitter with name or another id entifier, or tw o or more Patient Not Connected to Telemetry Monitoring Patient connected to in Figure 3. The most common event subtypes included: patients had their telemetry monitoring a new unit, and GP’s cardiac tracing immediately wrong telemetry Equipment as Ordered equipment switched, resulting in incorrect errors involving batteries in equipment (14.0%); errors monitoring equipment began displaying on the central monitor. GP had informa tion appearing on the telemetry in which patients were not connected to equipment as CM, a 62-year-old male with a history of diabetes technician’s central monitor for the patients gone unmonitored for about 45 minutes. The nurse ordered (12.9%); errors involving broken, damaged, or and congestive heart failure, came to the emergency in question contacted the after the event to notify them malfunctioning equipment (10.9%); and errors in which department with complaints of diarrhea for the past Telemetry monitoring was placed on about GP’s abnormal rhythm so that appropriate Telemetry monitoring patients were connected to the wrong equipment (9.0%). three days and a feeling of general weakness. The standby at some point and was not activated on standby treatment could be ordered for GP, but the monitor or reactivated at the appropriate time physician assistant who examined him determined Incidents and serious events were distributed malfunction delayed the notification. that he was dehydrated. CM was admitted and was Patient’s leads were either not connected to similarly across the various event subcategories. For Leads off or leads telemetry monitoring equipment, or they Battery Issues ordered continuous telemetry monitoring. The nurse this reason, it is our position that the level of harm failed were connected but not transmi tti ng for an in the signed off on the unknown reason associated with telemetry monitoring events may VH is a 72-year-old female with history of obesity, telemetry order but did not connect the equipment to depend largely on chance (i.e., the level of harm is not end-stage renal disease with dialysis three times per Patient was transferred from one unit to CM. Two additional nurses did not notice the order linked to certain subcategories of contributing factors, week, high , atrial fibrillation, right- another without a proper handoff (i.e., for telemetry monitoring and did not connect the Poor handoff patient was brought to the unit by staff from but rather to the patient’s underlying condition). sided heart failure, and asthma. After a trip and fall another unit and left without any at home, VH arrived at the emergency department equipment to CM. On the day following admission, communication between the staff members) Therefore, an analysis of all events—regardless of complaining of severe left hip pain, and an MRI CM was found in his room on the medical/surgical Telemetry monitoring harm level—will contribute a considerable amount of revealed a fracture. She was admitted and was ordered unit without a pulse. A code was called, and CM was technician unable to Telemetry monitoring staff were information to the current knowledge base. notify nursing unit of unsuccessful at contacting nursing staff to continuous telemetry monitoring. The nurse caring successfully resuscitated and transferred to the ICU. alarm conditions notify them of potentially life-threatening for VH in the emergency department connected the The order for telemetry monitoring was later found and/or delayed changes in rhythm, or nursing unit staff Case Vignettes response on nursing were notified but delayed in responding equipment prior to transferring VH to the inpatient in CM’s chart; he had been unmonitored for about 18 unit unit. On the second day following admission, while hours, so his rhythm prior to the event was unknown. M iscommunication Telemetry monitoring unit was not made The following are examples of each subcategory of between telemetry aw are of patient transfe r betw een rooms or VH was resting comfortably in her room after dinner, monitoring unit and units, or monitori ng was discontinued in telemetry monitoring event. These examples are Patient Off Unit Without Telemetry Monitoring her nurse checked her at 6 p.m. They were nursing unit error *PA-PSRS is a secure, web-based system through which Pennsylvania unremarkable except for a slightly elevated CV, a 75-year-old female with a history of atrial Telemetry monitoring Review of patient’s telemetry monitoring hospitals, ambulatory surgical facilities, abortion facilities, and birthing unit failed to notify history revealed an alarm condition that was of 105 beats per minute. VH reported to the nurse fibrillation, hypertension, and angina, was receiving centers submit reports of patient safety–related incidents and serious nursing unit of alarm not communicated to nursing staff or other events in accordance with mandatory reporting laws outlined in the that she was feeling fine. Later that evening, the a continuous infusion of diltiazem and heparin and conditions clinicians Medical Care Availability and Reduction of Error (MCARE) Act (Act 13 of had orders for continuous telemetry monitoring. 2002). All reports submitted through PA-PSRS are confidential, and no nurse entered the room and found VH slumped over Telemetry monitoring Telemetry monitoring equipment was information about individual facilities or providers is made public. Her physician ordered an MRI, and when the equipment broken, in her bed without a pulse. A code was called, but VH physically damaged or was not functioning damaged, or †“Incident” is defined as an event, occurrence, or situation involving the technician arrived to transport CV for testing, he properly could not be resuscitated and was pronounced dead malfunctioning clinical care of a patient in a medical facility which could have injured disconnected her telemetry monitoring equipment Telemetry transmitter’s batteries were dead, the patient but did not either cause an unanticipated injury or require at 8:45 p.m. After the event, it was discovered that the delivery of additional healthcare services to the patient.2 Battery issues d a ma ged i n so me w a y , o r i mpro perl y the batteries in the telemetry monitoring transmitter and did not notify the nurse. Soon after, the nurse inserted ‡“Serious Event” is defined as an event, occurrence, or situation involving had died; the last reading was taken at 7:10 p.m., so discovered that CV was off the nursing unit without Alarm was turned off, alarm volume was the clinical care of a patient in a medical facility that results in death Alarm issues turned d ow n, or alarm settings w ere or compromises patient safety and results in an unanticipated injury VH’s heart rhythm prior to the event was unknown. telemetry monitoring. The nurse immediately went 2 changed requiring the delivery of additional healthcare services to the patient. 40 I PatientSafetyJ.com I December 2019 Patient Safety I December 2019 I 41 Figure 4: Key Takeaways From Telemetry Monitoring Events to the testing area with the necessary Communication Breakdowns finally able to speak with HR’s nurse, who checked on modified, leading to situations in which clinicians were equipment, reconnected CV to telemetry Poor Handoff HR and reconnected his telemetry leads. In all, HR had unaware of heart rhythm changes. Communication monitoring, and remained with her until been unmonitored for over three hours. breakdowns among clinicians were also widespread RS, a 22-year-old female suspected of her test was complete. The nurse then among reports, from poor or nonexistent handoffs to having Wolff-Parkinson-White syndrome, accompanied CV back to the nursing Miscommunication Between Telemetry Monitoring failures in communicating changes in patient location was admitted through the emergency de- unit. CV was off the monitor for about Unit and Nursing Unit or status between units. partment for a full cardiac workup with 20 minutes. KM, a 55-year-old patient with a history of hyper- Harm associated with orders for continuous telemetry moni- Overall, facilities may benefit from clear processes and telemetry monitoring tension and high cholesterol, was admitted to the Patient Connected to Wrong toring, which was initiated in the emer- training on the proper use of equipment for all health- is rare but potentially hospital following a heart attack. She was ordered catastrophic, with Telemetry Monitoring Equipment gency department. RS was transported continuous telemetry monitoring, which was initiated care providers who may encounter telemetry monitoring death being the most LM, a 58-year-old female with a history from the emergency department to the in the emergency department. After her arrival on the as a regular part of their job, to ensure that all patients frequent outcome of ventricular fibrillation, and GR, a medical/surgical unit by a technician. telemetry unit, KM was initially placed in room 1254, are monitored safely and that no medical device takes among serious events. 35-year-old female with a history of After being notified that RS would be but after a fall from her bed, KM was moved to room the place of clinical care, observation, and judgment. A supraventricular tachycardia, were both arriving, the nurse on the medical/surgi- 1220 so she could be closer to the nurses’ station to closed-loop communication protocol that outlines spe- on continuous telemetry monitoring and cal unit registered telemetry monitoring prevent another fall. The move was not reported to cific escalation strategies should be written and reviewed hospitalized in the same room. At some equipment for RS and placed it on the the telemetry monitoring unit when it took place. The with all staff, especially when clinicians and monitoring 1 point, their equipment was disconnected counter in the room. Not seeing anyone telemetry monitoring technician observed that KM’s staff are in different locations. In addition, facilities immediately available for a handoff upon should follow the most up-to-date practice standards on Battery issues were one and mixed up before being reconnected. cardiac rhythm was not visible on the monitor, so arrival to the unit, the technician brought of the most common GR was experiencing a rapid heart rate, they called to notify KM’s nurse. The nurse informed continuous cardiac monitoring in the hospital setting to contributing factors but LM’s tracing reflected the rapid rate RS directly to her room and removed the the technician that KM had been transferred to a ensure this technology is not overused, as this has been 3 identified in telemetry because of the mix-up. In response to emergency department’s equipment. different room and was bathing. The technician tied to alarm fatigue among healthcare providers. monitoring events. the change in rhythm, LM’s physician The technician did not connect the new then updated the patient’s location in the telemetry ordered a diltiazem infusion, but the equipment and did not notify the nurse monitoring system. Limitations equipment mix-up was discovered before that RS had arrived on the unit. When Despite mandatory event-reporting laws in Pennsylvania, the infusion was started. Because both walking by, the nurse noticed RS in the Alarm Issues our data are subject to the limitations of self-reporting. patients had been improperly monitored room. RS informed the nurse that she JR, a 76-year-old patient with a history of hyperten- The annual number of telemetry monitoring event for several hours, the nurse for each had been waiting there for about 25 min- sion, high cholesterol, and atrial fibrillation, presented Communication break- reports submitted to PA-PSRS increased from 2014 patient went back over the alarms for utes. The nurse then placed RS on telem- to the emergency department with a chief complaint downs among clinicians, etry monitoring and found her heart rate through 2018, but this upward trend may simply technicians, and units are the preceding hours. The monitor mix- of palpitations and dizziness for the past two days. to be elevated at 135 beats per minute. highlight a growing use of telemetry monitoring or another common contrib- up was reported to the physician, who JR was admitted to the hospital and was ordered con- an increased awareness and reporting of telemetry uting factor related to te- decided to keep both patients overnight Telemetry Monitoring Technician tinuous telemetry monitoring. The oncoming nurse lemetry monitoring events. monitoring events in Pennsylvania healthcare facilities. for observation. Unable to Notify Nursing Unit of reviewed JR’s alarm log and discovered that he had Alarm Conditions and/or Delayed experienced a 21-beat run of ventricular tachycardia Because a standard taxonomy for reporting telemetry Telemetry Monitoring Equipment on Response on Nursing Unit and a run of atrial flutter during the previous shift, monitoring events does not exist, it is possible that Standby despite being told that the patient had no episodes of relevant event reports were missed with our query. In A telemetry monitoring technician MK, an 81-year-old female, was admitted irregular rhythms. Upon further investigation, it was addition, equipment and practices vary greatly from observed that HR, a 65-year-old male to the hospital with complaints of short- found that the alarm volume on the telemetry moni- one facility to another, and event details often referred Improper alarm settings, with a history of right-sided heart failure, ness of breath. A cardiac catheterization tor at the nurse’s station had been turned completely broadly to telemetry without specifying a particular including volume being was disconnected from his telemetry was ordered. Prior to the procedure, MK’s down, therefore no one had heard the alert. device, component, or practice. For this reason, we turned down or alerts monitoring equipment. The technician being changed, also telemetry monitoring was put on stand- used the label “telemetry monitoring equipment” (or attempted to page HR’s nurse four contributed to telemetry by mode. She returned to her room fol- Discussion “equipment” for brevity) to include devices, monitors, monitoring events. times, but a nurse was not signed in to lowing the procedure, but the equipment electrodes, leads, wires, and monitors. receive pages for HR. The technician then was not taken off standby. Several hours Several important lessons can be learned from our contacted the charge nurse to inform later, the nurse found MK unresponsive analysis, which are summarized in Figure 4. Although them that HR had been unmonitored for Conclusion on the floor next to the bed. A code was telemetry monitoring events do not frequently result an hour and a half. The charge nurse in patient harm, the events that do cause harm may called, and MK was successfully resusci- This analysis revealed that, although patient safety assured the technician that someone be catastrophic, typically leading to patient death. The tated and transferred to the ICU. After events associated with telemetry monitoring do not would check on HR to ensure that his most commonly reported causes of telemetry moni- the event, the nurse discovered that the often result in harm, those events that do lead to leads were attached. After another hour, toring errors were problems with dead or improperly Failures to follow orders, telemetry monitoring equipment had re- harm most often result in death. Both incidents and the patient was still unmonitored, so the inserted batteries in the telemetry transmitter. In ad- procedures, or protocols mained on standby when MK returned to serious events were distributed across the various among hospital staff technician reached out again and was dition, many reports described alarm settings being the unit after her procedure. event subcategories. In addition, the reporting of members were a factor in many telemetry monitoring events. Patient Safety I December 2019 I 43 patient safety events associated with telemetry About the Authors monitoring increased from 2014 to 2018. Elizabeth Kukielka ([email protected]) is a patient The most common telemetry monitoring events safety analyst on the Data Science and Research team were related to user errors, including patients not at the Patient Safety Authority. Before joining the being connected to monitoring as ordered and PSA, she was a promotional medical writer for numer- patients being connected to the wrong monitor, and ous publications, including Times and The to equipment malfunctions, including damaged or American Journal of Managed Care. Kukielka also broken monitors or monitors with dead batteries. It worked for a decade as a community pharmacist and may be prudent for healthcare facilities to focus their pharmacy manager, with expertise in immunization attention on policies and processes surrounding delivery, diabetes management, medication initiation of continuous telemetry monitoring and management, and pharmacy compounding. daily care of equipment, including timely replacement of leads, patches, and batteries. Kelly R. Gipson is a project manager at the Patient Safety Authority. She started with the PSA as a In addition, biomedical and clinical engineering staff patient safety liaison for the South Central region of play a critical role in ensuring proper maintenance Pennsylvania. Prior to joining the PSA, she worked as of monitoring equipment. Any staff member who the associate patient safety officer at WellSpan York encounters or works with patients on telemetry Hospital in York, Pennsylvania. Her clinical background could benefit from training on the steps necessary includes experience in medical/surgical, critical care, to initiate or maintain appropriate monitoring. In and recovery room settings, as well as on multiple addition, lines of communication between clinicians hospitalwide shared decision-making committees. on the frontline and technicians responsible for remote telemetry monitoring should always be kept Rebecca Jones is director of Data Science and open to ensure patients receive safe care throughout Research at the Patient Safety Authority, where she their hospital stay. also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous Notes roles at the PSA include director of Innovation and Strategic Partnerships, and regional patient safety This analysis was exempted from review by the liaison. Before joining the PSA, Jones served in various Advarra Institutional Review Board. roles leading patient safety efforts and proactively managing risk in healthcare organizations. She References currently is chair of the Practice Committee of the 1. Sandau KE, Funk M. What Happened on Telemetry? Patient Safety Society to Improve Diagnosis in and serves Network. 2019. on the Advisory Committee of the Coalition to 2. Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002). Improve Diagnosis.

3. Sandau KE, Funk M, Auerbach A, Barsness GW, Blum K, Cvach M, et This article is published under the Creative al. Update to Practice Standards for Electrocardiographic Monitoring Commons Attribution-NonCommercial license. in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation. 2017;136(19):e273-e344. Epub 2017/10/05 doi: 10.1161/CIR.0000000000000527. PubMed PMID: 28974521.

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