Cardiac monitors – wrong patient name

There is a new alert from the patient safety organization, ECRI. They advise healthcare professionals to be alert to the risks of improperly identified cardiac monitors. Here is what happens. A patient in an intensive care unit or a telemetry unit is hooked to a cardiac monitor. A nurse or technician watches the monitor for potentially serious irregular heart rhythms. The nurse takes action when these show up on the monitor. In several instances, the wrong patient was hooked up to the monitor. This left the patient who needed the monitor without this critical observation. If the wrong patient is monitored, the staff may be too late in recognizing a serious heart rhythm. Several patients have died.

How does this monitoring error happen? These are some of the factors.

  • not following procedures
  • not receiving orientation to the procedures
  • not identifying the patient correctly
  • not communicating within the healthcare team
  • inexperience
  • distractions
  • machine failures
  • equipment not available

Here is ECRI recommended healthcare providers do:

  • Confirm the identity of the patient using two identifiers, such as name, birth date, or patient identification number.
  • Use systems to confirm that the right receiver is attached to the right patient.
  • If more than one cardiac monitor is being watched at a central monitoring area, the monitor has to be labeled with the patient identifier. Two staff should confirm the correct labeling.

Here is what you can do:
If your family member or friend is admitted to a nursing unit, talk to the physician about the medical plan. Ask if the patient is supposed to be on a cardiac monitor. Confirm that the monitor was set up. (You will see this in the patient’s room.) If so, look at the monitor in the patient’s room to see if the name is correctly displayed on the monitor.

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