Health Care Quality Case Study Case Presentation While hospitalized on a cardiac step-down unit, a patient undergoing cardiac monitoring died when a lethal cardiac rhythm was missed by the hospital staff

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Health Care Quality Case Study

Case Presentation

While hospitalized on a cardiac step-down unit, a patient undergoing cardiac monitoring died when a lethal cardiac rhythm was missed by the hospital staff. Because of the severity of the outcome, a root cause analysis (RCA) was done. The root cause analysis determined the central monitor screens for the cardiac units were at the nurses' stations, giving them primary responsibility for oversight. However, the RNs were so busy that the unit secretaries were eventually trained to watch the monitors because they sat at the desk where the monitors were located.

The unit secretaries were also very busy, making it impossible to keep a constant eye on the cardiac monitors resulting in inconsistent monitoring, reporting, and follow-up related to monitor alarms. During the RCA, it was determined that the nurses did not intend the secretaries to be the only pair of eyes on the monitors and had every intention of being closely involved. Secretaries were instructed to notify the RN of any monitor alarm, and it was the nurse's responsibility to respond. However, when the nurses assigned the responsibility to the secretaries, they became complacent of their primary responsibility to ensure someone observed, reported, and responded to any alarm. In the case of the death, the secretary had learned to silence the monitors once she had alerted the nurse because the noise was overwhelming. The secretary reported, "I had seen the nurses do it all the time because they often complained that patients turning over could cause the alarms to go off." This statement was corroborated by the nursing staff, and they admitted they often instructed the secretaries to "shut it off," based on their having just been in the patient's room several times for monitor alarms and the patient was fine.

On the day of the event, the monitor was alarming and the secretary told the nurse as usual, but on her way to the patient's room, the nurse was called to an emergency at the other end of the hall, preventing her from checking the patient immediately. The secretary silenced the alarm on two subsequent times once she had notified the nurse, thinking it had been addressed. The patient had been in ventricular fibrillation and died before the nurse returned to the room.

During the investigation, it was discovered there had been five other incident reports filed for similar problems over the past 2 years, including two near-death cases. In a review of the other incident reports, it was documented that the solution to the early problems had been to train the secretaries as a backup because the nurses were often in the hallways or in patients' rooms. It was believed that having someone who was always near the monitors and who could watch them and report alarms to the nurses would solve the problem. It became clear, based on the recent death, that a more drastic solution was needed. After analyzing several proposed solutions, it was decided that having a centralized monitor room separate from the nursing station monitors and staffed with monitor techs was the best solution. In addition to the centralized monitor room, the ability to silence a monitor was removed from the central unit at the nurses' station, so the alarm could only be silenced by an RN at the patient's bedside to ensure someone had seen the patient before silencing the alarm. Finally, in the event of a lethal alarm, the monitor room techs would call a code blue before phoning the nursing unit.

 

Case Analysis

This model case illustrated a system failure that did not meet the major attributes of health care quality of being safe, patient-centered, timely, effective, and efficient. This effort would be classified as a sentinel event because there was a severe variation in the standard of care caused by both human error and system error, resulting in death.

 

Questions

 

1. it is interesting that at the end of Root Cause Analysis and evaluation for changes to increase patient outcomes, it came down to adding an additional telemetry tech that is responsible for monitoring patients on telemetry (this is not an unusual occurrence; and in larger tertiary hospitals it kind of standard of care). However this does not usually happen in smaller hospitals. 

 

So, knowing what their decision is as this point; if you were the nurse manager for this unit/hospital, is there anything else you can think of that may help to mitigate risk, and prevent another sentinel event?