Bryn Mawr Hospital Left Patients Without Monitors

By Walter F. Roche Jr.

Physician ordered cardiac monitors were not provided to five patients at the Bryn Mawr Hospital and one of the five was critically ill and in need of immediate attention, according to a state Health Department report.
The 287-bed hospital, part of Main Line Health, also failed to assign registered nurses to accompany the emergency room patients, who were awaiting further testing.
The hospital, the report states, "failed to maintain a safe environment for Emergency Department patients ordered to receive continuous cardiac monitoring."
"Continuous cardiac monitoring, no exceptions," the physician's Sept. 19 admission order stated.
"I guess I should have looked closer at the physician's admission orders," a staffer said when asked by surveyors about the lack of a monitor.
The report details the handling of the critically ill patient including the failure of staffers to respond to test results showing the patient's potassium levels were nearly double the normal level.
When state surveyors interviewed staffers involved in the case they acknowledged mistakes were made, including the failure to notify the physician about the potassium levels.
Instead they mistakenly assumed the sample had become contaminated and debated whether to do a re-test.
"In hindsight if I had this to do all over again I would have called the physician and/or the physician's assistant for a final decision about the test results," one hospital employee told the state inspectors.
Another employee told inspectors they assumed the test result was wrong because that level of potassium was "not compatible with life."
Main Line Health officials did not respond to a series of questions about the report including whether the patient survived.
Instead they issued a statement asserting that all the issues adressed in the report had been adressed.
"We are confident that our action plan addresses the issues identified, and demonstrates Bryn Mawr Hospital’s ongoing commitment to a culture of safety and highly reliable, quality care," Megan Call, a Main Line spokeswoman wrote in an email.
She said a corrective action plan had been submitted to the state, although the state report says an approved plan is not on file.
According to the state report, a review of hospital records showed incorrect information about the patient's heart rhythm had been entered.
The report also faults the hospital for failing to record a baseline cardiac rhythm and failure to raise his triage level, condition srable, despite the test results.
"The facility failed to ensure emergency department patients received an acceptable standard of nursing care," the report states.
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