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. 62019 paper published in Patient Safety reviewed 558 reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) 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.