Mariah Taylor (Email) Becker’s Hospital Review
Last year, a patient at Aurora, Colo.-based Rocky Mountain Regional VA Medical Center died after a hospital technician turned off their notification device, the Canon City Daily Record reported Aug. 15.
The VA’s Office of Inspector General investigated the situation in spring 2023. It found a telemetry medical instrument technician missed several red alarms concerning a patient’s oxygenation levels. By the time clinicians arrived, the patient was “unresponsive and pulseless.” A patient safety report was not filed for the patient’s death, investigators said.
Technicians receive alerts depending on patients’ conditions and are supposed to alert nurses if there are rapid changes. Hospital staff told investigators that this technician was known to change patient alarm settings and place communication devices on “do not disturb” for long periods of time. Leadership became aware of these habits in September 2022, the report noted, and conducted a meeting that explained expectations. Nurse managers were supposed to complete audits of alarm monitoring a few times a month, but no records could be provided to investigators.
The inspector general expressed “concern that the lack of clinical alarm management oversight could result in an increased risk for the occurrence of patient safety events.”
The investigation concluded that the delay in alarm notifications could have resulted in serious injury to the patient and possibly contributed to the patient’s death. Due to the patient’s comorbidities and complexity of care, investigators could not determine if the failures affected clinical care.
Investigators found a second instance where a patient experienced a cardiac event, but clinicians were unaware for hours due to the patient’s alarm being turned off.
Hospital leadership removed the two technicians involved in the incidents from patient care.
The VA told the news outlet that they “regret the circumstances surrounding the care of these veterans,” and pledged to take “significant actions to improve our telemetry and alarm monitoring processes as a result of this review.”
The hospital has revised their telemetry policy; agreed to regular monitoring and audits to ensure compliance; require patient safety manages to track all patient safety reports to ensure monitoring and accountability; and have tasked the hospitals’ risk manager with tracking and categorizing adverse events and sharing findings with executive leadership, Janelle Beswick, a regional VA spokesperson, told the Record.
