Alarm Interventions during Medical Telemetry Monitoring: A Failure Mode & Effects Analysis
MedSun: Newsletter #24, May 2008
Pennsylvania Patient Safety Authority
Summary: 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. PA-PSRS analysts conducted a failure mode and effects analysis (FMEA) on alarm interventions during medical telemetry because of the potential for serious patient harm or death. 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.
Alarm Interventions during Medical Telemetry Monitoring: A Failure Mode & Effects Analysis. Pennsylvania Patient Safety Authority. March 2008.