A nurse holding their  telemetry pager.
Reporting a Problem Catches Unrecognized Systemwide Failure

​​​At around 10 p.m. on a Sunday, a registered nurse reported to her unit director that her telemetry pager was not receiving alarms for a patient with arrhythmias, although it had been working when she came on the night shift at 7 p.m. When her pager also didn’t receive the test page she sent, she test paged all the other RN’s pagers on her unit and discovered none of them were working. She stationed an RN at the telemetry monitor to watch all the patients being monitored and checked with the nursing supervisor. Although none of the other units had reported an issue, this was only because they hadn’t noticed their pages weren’t receiving alarms until the RN brought the problem to their attention. She notified clinical engineering of the hospitalwide outage, which rebooted the system; pager alarms were functioning again by 12:30 a.m. The RN’s attentiveness and diligence ensured that no critical alarms went unnoticed and unaddressed during system downtime and quickly resolved a serious problem that no one would have been aware of otherwise.