Between June 2004 and October 2006, PA-PSRS received 277 reports related to alarm response during medical telemetry monitoring. All of the reports described events in which patients were not consistently monitored for physiologic conditions, and three events resulted in patient death. Telemetry physiologic monitoring systems generate visual and audible alarm signals based on changes in patient physiologic conditions that exceed alarm limits established for a specific patient or a particular patient population. When a clinician does not respond or delays response to an alarm, appropriate patient care may be compromised, possibly resulting in a poor patient outcome.
Figure. A Failure Mode & Effects Analysis
PA-PSRS analysts conducted a failure mode and effects analysis (FMEA) on alarm interventions during medical telemetry monitoring because of the potential for serious patient harm or death. FMEA is a proactive risk assessment method used to evaluate a system or process in order to identify potential failures and develop and implement mitigation strategies to reduce or eliminate failures before they occur. Healthcare facilities can use the published results of this FMEA to understand telemetry monitoring alarm response processes and similar process failures and as an aid to develop facility-specific risk reduction strategies. The complete monograph, “Alarm Interventions during Medical Telemetry Monitoring: A Failure Mode and Effects Analysis,” is available on the Pennsylvania Patient Safety Authority’s Web site.
