By Walter F. Roche Jr.
Staff at a Lancaster hospital mixed up the monitors assigned to two patients resulting in the wrong medications and tests being ordered for one of those patients, according to an Oct. 8 report from the Pennsylvania Health Department.
The incident occurred on July 20 at the 525-bed Lancaster General Hospital and involved two patients who were admitted around the same time and sent to the same telemetery unit.
The hospital's administrators "failed to adopt a policy directing staff how to identify which patient has which telemetry unit," the report states, adding that as a result medications and tests were ordered "based on the incorrect telemetry readings."
State surveyors in an October visit to the Penn Medicine facility found that hospital records showed one of the patients who had an irregular heart rhythm "appeared to simultaneously convert to a normal sinus rhythm upon arrival at the unit but patient was not actually in normal sinus rhythm."
The patient actually was still experiencing atrial fibrillation, the seven-page report continues, adding that the error was later discovered after nurses observed and conversed with the patients.
The report does not indicate if the mixup resulted in any adverse effects, but concludes that tests and medications ordered were based on the incorrect telemetry readings. Penn Medcine officials did not respond to questions about the report.
The state inspectors also faulted the facility for failure to maintain records showing which employee obtained the telemetry units and who placed them on the patients.
The hospital "failed to ensure nursing documentation was pertinent, accurate and concise," according to the report
In a plan of correction filed by the hospital and accepted by the state, administrators said new systems had been put in place to ensure that the right monitor was placed on the right patient.
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