Read about ongoing risks associated with cardiac telemetry monitoring and some tips to mitigate them. Also in this issue: a webinar on making healthcare workplaces safer, new patient safety tips for using bedrails, and more.
Please share this information with your contacts to ensure everyone has the knowledge and tools to help keep safe.
Keeping Watch: Reviewing Recent Telemetry-Related Events in Pennsylvania Facilities
In the inpatient setting, cardiac telemetry monitoring (or continuous cardiac monitoring) enables healthcare workers to quickly detect and diagnose cardiac arrhythmia.1 Previous research has demonstrated that patients at high risk for a cardiac-related event can benefit from telemetry monitoring.2 However, telemetry monitoring has also been associated with negative patient outcomes due to overuse,3,4 alarm fatigue,4,5 and other telemetry-related complications.6
A 2019 paper published in Patient Safety reviewed 558 reports submitted to the Pennsylvania Patient Safety Reporting System (PAPSRS) over a five-year period that were related to telemetry monitoring.6 In this paper, telemetry monitoring events were associated with user errors, communication issues between healthcare providers, equipment malfunctions, and alarm issues.6
Telemetry-related safety events continue to be reported to PA-PSRS. A review of recently submitted event reports describe mismatches between patients’ telemetry box numbers and central monitoring, prolonged connections to telemetry boxes with dead batteries, failure to connect patients to telemetry monitoring as ordered, and lack of response to telemetry alarms. The most recent telemetry-related reports include both incidents and serious events and show that telemetry-related safety issues remain a persistent patient safety issue. Notably, at least two recent events resulted in patient deaths.
This recent exploration shows that despite previous research identifying telemetry-related patient safety events and providing risk mitigation strategies, events similar to those summarized in the 2019 article6 are still occurring. The Patient Safety Authority (PSA) has provided telemetry monitoring tips7 to mitigate these types of events and a toolkit8 for investigating telemetry-related events. PSA encourages facilities to review these materials to reduce the risk of encountering future telemetry-related events. Examples of mitigation tips from these resources that are relevant to the reports described above include:
- Review the practice standards for electrocardiographic monitoring in hospital settings by the American Heart Association (AHA).1
- Include telemetry monitoring verification as a standard part of the hand-off process.7
- Create a process to identify patients who have orders for telemetry but are not being monitored.7
- Inventory all telemetry batteries.7
- Determine the battery life for each type of battery.7
- Develop a consistent schedule around battery changes.7
- Reduce false and clinically irrelevant alarms by preparing the skin when electrodes are applied, changing electrodes per a defined schedule, and individualizing alarms to each patient.7
Telemetry monitoring remains a critical part of inpatient care,1,2 but ongoing system and human factors continue to pose a risk to patient safety.3-6 Consistent application of evidence-based standards, proactive maintenance, and staff education can reduce preventable errors and enhance monitoring reliability to improve patient safety.3-7
References
- Sandau KE, Funk M, Auerbach A, et al. Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation. 2017;136(19):e273-e344. Epub 2017/10/05. doi:10.1161/CIR.0000000000000527; PubMed PMID: 28974521
- Cantillon DJ, Burkle A, Kirkwood D, et al. Indication-Specific Event Rates Among Hospitalized Patients Undergoing Continuous Cardiac Monitoring. Clin Cardiol. 2019;42(10):952-7. Epub 2019/08/14. doi:10.1002/clc.23244; PubMed PMID: 31407351; PubMed Central PMCID: PMCPMC6788477
- Bergstedt A, Hilliard B, Alabsi S, et al. Evaluation of a Clinical Decision Support Tool to Guide Adoption of the American Heart Association Telemetry Monitoring Practice Standards. J Am Heart Assoc. 2024;13(9):e031523. doi:10.1161/JAHA.123.031523; PubMed PMID: 38686881; PubMed Central PMCID: PMCPMC11179861
- Gipson KR. Telemetry Monitoring: Improvement Strategies for Everyone. Patient Safety. 2021;3(2):104-107.
- Drew BJ, Harris P, Zegre-Hemsey JK, et al. Insights Into the Problem of Alarm Fatigue With Physiologic Monitor Devices: A Comprehensive Observational
- Study of Consecutive Intensive Care Unit Patients. PLoS One. 2014;9(10):e110274. doi:10.1371/journal.pone.0110274; PubMed PMID: 25338067; PubMed Central PMCID: PMCPMC4206416
- Kukielka E, Gipson KR, Jones R. A Brief Analysis of Telemetry-Related Events. Patient Safety. 2019;1(2):36-44. doi:10.33940/biomed/2019.12.4
- Patient Safety Authority. Telemetry Monitoring in Pennsylvania Tips and Strategies to Prevent Alarm Fatigue. PSA. https://patientsafety.pa.gov/pst/Documents/Patient Care — Telemetry/Telemetry Monitoring Tips and Strategies.pdf. Accessed November 2025.
- Patient Safety Authority. Hospital Telemetry Event Investigation Tool. PSA. https://patientsafety.pa.gov/pst/Documents/Patient Care —Telemetry/TelemetryEventInvestigation_2020_10.pdf. Updated October 2010.Accessed November 2025.
Safety Tips for Patients and Their Families
What Should I Know About Bedrails?
Bedrails may provide support for someone in a hospital bed or stretcher. (A stretcher is sometimes called a gurney.) Bedrails can give patients something to hold onto when sitting up or moving around in bed.
At times, like after surgery, they can prevent patients from falling out of bed. However, bedrails may pose significant risk of injury to some patients. They may also be considered a restraint if a patient cannot lower them to exit the bed on their own. This is often why healthcare providers only raise some of the bedrails or none at all.
What are the risks when using bedrails?
- “Entrapment” is when a patient gets caught in the bedrail, mattress, or bedframe. Entrapment can cause serious harm, like broken bones and death (often by suffocation).
- Some patients may try to exit the bed by crawling over the bedrails. This often happens when patients are confused or disoriented. This also leads to a high risk of serious injury and/or death.
These risks should be weighed against the benefits of using bedrails. Talk to the healthcare team if you have concerns.
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Subscribe to the Patient Safety Authority's YouTube channel to watch our archive of webinars and other educational videos, like this series about telemetry monitoring in Pennsylvania.
Just Published in Patient Safety
Standardizing IV Electrolyte Administration in Pediatric Oncology: A Quality Improvement Initiative
Our bodies rely on electrolytes like soluble salts, acids, and bases to ionically conduct electricity for healthy muscle and nerve function. Pediatric oncology patients may experience imbalances in electrolytes resulting from cancer or treatment, which could lead to an oncologic emergency—which is why registered nurses (RNs) carefully manage patients’ electrolyte levels with intravenous (IV) administration of electrolytes. However, the Institute for Safe Medication Practices has designated some IV electrolytes as high-alert medications that carry their own risk of harm if they are used in error. To reduce this risk, one facility embarked on an initiative to improve pediatric care by standardize the ordering and administration of electrolytes.
Recognizing that variability in nursing practice regarding high-risk IV infusions could lead to patient harm events, the improvement team studied their existing procedures and challenges around administering large doses (boluses) of electrolytes. They then developed interventions, with the goal of increasing the proportion of administrations where the documented electrolyte bolus (EB) infusion rate matches the ordered EB infusion rate from a baseline of 15% to 60%. Interventions included clarifying and standardizing EB policies, supported by RN job aids and formulary guidance. Due to their efforts, through multiple Plan-Do-Study-Act cycles from January 2022 to March 2024, they surpassed their goal with 85% compliance of EBs administered at the ordered rate.
Lessons From Event Reports
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.
