Cardiac Monitor Silenced, Patient Dies

By Walter F. Roche Jr.

A monitor technician at a Philadelphia hospital turned off a cardiac monitor alarm and the patient was found dead about 20 minutes later during a routine check by a nurse, according to a report by the Pennsylvania Department of Health.
The report on the Nazareth Hospital in Northeast Philadelphia cited the facility for "failure to ensure the well being of the patient by failing to respond to a cardiac monitor alarm as per facility policy."
According to the inspection report, a monitor technician on duty on Dec. 7 of last year "did not correctly identify a change" and silenced the alarm without verifying the rhythm or notifying the nursing staff of the alarm.
Nazareth, part of the Mercy Health System declined, to answer a series of questions about the incident but issued a brief statement.
"The safety of our patients is our top priority, and we maintain strict procedures to promote a positive, healing environment and to ensure patient confidentiality," Christy McCabe wrote in an email response to questions.
"We work closely with the Pennsylvania Department of Health and other regulators to ensure we continually implement best practices for patient safety," the statement concluded.
McCabe did not respond to questions including whether any action was taken against the technician or whether the new telemetry equipment has been put into use.
Nazareth, a 200-bed hospital, did file a plan of correction with the state in which they promised to re-educate technician monitors. They also said those technicians were tested by a Feb. 28 deadline.
Nazareth also said it would install new telemetry equipment to help ensure the incident would not be repeated.
State inspectors, who visited Nazareth on Feb. 26 through Feb. 28, said records showed that by the time the nurse who found the patient called a code blue, more than 20 minutes had passed since the alarm sounded.
The patient could not be revived. The incident occurred late in the afternoon of Dec. 7.
The inspection report states that Nazareth failed to maintain good quality care and high professional standards by not following established cardiac monitors policies."
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