I Am Patient Safety 2018: Good Catch Award

Dawn Emes, BSN, RN, CMSRN
Lehigh Valley Hospital – Muhlenberg
I Am Patient Safety 2018 winner of the "Good Catch" award.

Late on a Sunday night, registered nurse (RN) Dawn Emes noticed that her telemetry pager, which tracks changes in patients' heart rhythms, was not sending alarms for a patient she knew had arrhythmias. The pager had been functioning properly at change of shift, three hours earlier. She found she was unable to send her pager a test page. Concerned, Emes tested all the RNs' pagers on the unit and found they also were not working. First, she stationed an RN at the telemetry monitoring station to watch all patients being monitored, recognizing the possibility of an event going unnoticed. Then she notified the nursing supervisor and asked if other units in the hospital were having this issue. Initially, she was told no; however, the nursing supervisor soon reported that the unit's pagers were not sending alarms to the nurses on other units, which had gone unnoticed. The clinical engineering department rebooted the system and alarms functioned again. Of all of the unit nurses with patients on telemetry, Emes was the only one to notice that it was a problem that alarms were absent and that the problem could be occurring across the hospital. While it cannot be said Emes prevented injury or death, she prevented all the patients in the hospital who were on telemetry from having a critical alarm go unnoticed and a serious problem potentially remain untreated.

©2018 Pennsylvania Patient Safety Authority