By Walter F. Roche Jr.
It took six hours for staff at a Pittsburgh hospital to realize a critically ill patient was no longer on a physician-ordered continuous cardiac monitor.
Not only that there were three other such incidences at UPMC Presbyterian Shadyside over a six month period, according to a report from the state Health Department, which was recently made public.
The latest incident prompted state Health officials to declare a state of "immediate jeopardy" which forced hospital officials to come up with an immediate correction plan.
Under that plan the hospital agreed to have 24/7 coverage of monitors showing the current stste of all working cardiac monitors.
"A monitor manager is located in the unit nursing station on each individual unit," the report states.
The immediate incident which triggered the state visit occurred on Oct. 25 and Oct. 26.
The unnamed patient's monitor stopped functioning at 10:13 p.m. but the patient was not found unresponsive until 4:14 a.m. the next day.
The state report dated Nov. 2 states that three prior "serious events" reported at the facility over a six month period were for the same issue; patients on physician ordered cardiac monitors found unresponsive and off monitors.
None of the three patients survived," the report states.
The report does not indicate whether the October patient, who was off moitor for some six hours, survived.
In the most recent case the surveyors found that the same patient had been found with evidence of internal bleeding but staff failed to inform the physician of the change in condition.
The report faults the hospital management, including the chief executive officer, the nursing staff and the hospital's governing body for the multiple failures.
UPMC filed a plan of correction in response to the latest incident which includes staff re-education and audits. Hospital officials did not respond to requests for comment.
Contact: wfrochejr999@gmail.com
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