Question

The nurse had another patient who also had frequent alarms, but his corresponded to actual medical events. As a result, the nurse was spending a great deal of time with this elderly gentleman and his wife. Each time she walked by Laura’s bed, the nurse noted that Laura was sleeping. She realized that it had been 2 hours since she turned off the alarm and called the biomedical technician, so she decided to check on Laura; however, her other patient’s alarm went off and, since Laura was sleeping, the nurse went to the other patient’s bedside. At 4 hours after the alarm had been turned off, the biomedical technician arrived and apologized because there was a call-off in their department and they were running shorthanded. The nurse explained what had happened and the biomedical technician went to check Laura’s monitoring equipment. The biomedical technician called for the nurse as the patient was unresponsive. The nurse could not wake Laura, and the monitor was showing asystole. A code was initiated and Laura was pronounced dead 5 hours after she arrived on the telemetry unit. This situation was assessed by the patient safety officer and the patient safety committee. Because the monitor was integrated and all functions ran through the same controller, the nurse did not realize she was turning off all of the monitors (pulse oximetry, blood pressure, etc.). This was found to be an issue with the equipment itself because the alarm settings are too close together and not clearly labeled; however, the nurse should never have turned the alarms off. With the hourly checks cancelled and all of the monitoring equipment silenced, Laura was not being monitored at all. Well-intentioned providers were allowing this young mother to sleep, but with fatal consequences.

1) Understanding that some safety features can be bypassed, what other safe-guards can be put into place in ensure patient safety? Name three methods.

2) In the case of Laura, create a work-flow that could be used to mirror the actions taken, then identify where in the work-flow improvements could be made to prevent the outcome shown in the scenario.

Answer 1

According to the given scenario

Safe guards to ensure patient safety

Manual method

There should be a more manual dependency instead of technology dependency. Nursing should check at least breathing pattern of sleeping patient.

Training method

There should be minimal training in nursing staff regarding operation of telemetry unit equipment and machines

Identification method

Separate color button should be used for different operation.there should not be single button for every operation.Technician should not run short handed as this is a matter of life and death.

2) 1) client observed by nursing staff from distance for longer duration

2) Technical issue of other patients

3) technician coming late at the site of error

4) informal training of nursing staff ultimately switched off all vitals

5 ) patient dies and then technical issue brought into consideration.

There are a lot more improvement which can be made

Observing client breathing pattern in case of sleeping hourly

Reading the user manual of machine carefully

Thanks