Physiologic alarm management
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Lacker, Cynthia. Pennsylvania. Patient Safety Authority. ECRI (Organization) Institute for Safe Medication Practices.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2011
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Clinical Alarms Monitoring, Physiologic -- methods Cause of Death Equipment Failure Equipment Failure Analysis Monitoring, Physiologic -- instrumentation Safety Management -- methods Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- In response to an inquiry, analysts from the Pennsylvania Patient Safety Authority queried the Authority's reporting system database for event reports of patient deaths related to physiologic alarm monitoring from June 2004 through December 2010. Using the keywords alarm, monitor, ECG [electrocardiogram], telemetry, pulse-ox, and defibrillator in combination with intensive care unit or telemetry unit, where death was mentioned or harm score signified death (i.e., "I"), staff identified 187 reports. Thirty five of the event reports indicated that patient death was related to some aspect of physiologic alarm management. The 35 event reports referenced the following types of monitoring equipment: (1) Blood pressure machine (n =1); (2) Bilevel positive airway pressure machines (n = 2); (3) Ventilators (n = 4); (4) Telemetry monitors (n = 28) The reports were categorized as either equipment (n = 4) or human (n = 31) failures.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages 105-108)).
- NLM Unique ID:
- 101570810 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101570810