Laura, a 25-year-old woman, arrived at the ER complaining of chest pain
Case Study 4:1
Laura, a 25-year-old woman, arrived at the ER complaining of chest pain. She has two young children at home, a 6-year-old boy and a 4-year-old girl. She stated that she has been experiencing severe fatigue and fluttering in her chest for weeks but felt that she needed rest and it was probably nothing. Today, she had the fluttering with chest pain, and even her teeth and jaw hurt. This scared her, so she decided to go to the hospital. However, she had to wait 2 hours for her mother to arrive to watch the children. Her husband is on a business trip and will not be returning for 4 days. The initial ECG revealed normal sinus rhythm, and all lab values were normal. The emergency room physician decided to keep her for observation and sent her to the telemetry unit.
Laura was moved to telemetry and, as she stated, “wired for sound.” The nurse described the equipment and told her that in addition to all of the monitoring equipment, they would check her vital signs every hour as well. The nurse no sooner returned to the nurse’s station when Laura’s cardiac monitor alerted her that Laura was experiencing severe bradycardia (i.e., heart rate of less than 40 beats per minute). When the nurse arrived at Laura’s bedside, she found Laura sound asleep. She woke her gently and told her that her monitor was alarming and that she was going to check her. Laura stated that she felt tired and was enjoying the peaceful sleep. Laura’s vital signs were fine and her heart rate was 72 beats per minute. The nurse reset the monitor, by which point Laura had already fallen back to sleep. The monitor alarmed the same way three more times within the next hour. Each time, the nurse woke Laura and everything was fine. The nurse decided to contact the resident. While she was waiting for the resident, it alarmed twice again, but she just reset it and let Laura sleep. The resident came and examined Laura. The resident felt everything was OK and that this young mother needed her rest. The resident suggested that the nurse stop the hourly vitals; call and have the equipment examined by the biomedical department; and, in the meantime, tum the alarm off. The nurse agreed, turned off the alarm, placed a call to the biomedical technician on duty, and left a message.
The nurse had another patient who also had frequent alarms, but his corresponded to actual medical events. As a result, the nurse was spending a great deal of time with this elderly gentleman and his wife. Each time she walked by Laura’s bed, the nurse noted that Laura was sleeping. She realized that it had been 2 hours since she had turned off the alarm and called the biomedical technician, so she decided to check on Laura; however, her other patient’s alarm went off, and since Laura was sleeping, the nurse went to the other patient’s bedside. At 4 hours after the alarm had been tured off, the biomedical technician arrived and apologized because one of the other techs called off sick in their department and they were shorthanded. The nurse explained what had happened, and the biomedical technician went to check Laura’s monitoring equipment. The biomedical technician called for the nurse because the patient was unresponsive. The nurse could not wake Laura, and the monitor was showing asystole. A code was initiated, and Laura was pronounced dead 5 hours after she had arrived on the telemetry unit.
This situation was assessed by the patient safety officer and the patient safety committee. Their determination was that because the monitor was integrated and all functions ran through the same controller, the nurse did not realize she was turning off all of the monitors (e.g., pulse oximetry and blood pressure). This situation was found to be an issue with the equipment itself because the alarm settings are too close together and not clearly labeled; however, the nurse should never have turned the alarms off. With the hourly checks canceled and all the monitoring equipment silenced, Laura was not being monitored at all. Well-intentioned providers were allowing this young mother to sleep but with fatal consequences.
It is evident from the case scenario that we have yet to find a solution to the problem of alarm fatigue and related issues that negatively affect patient safety.
Clearly, there is more work to be done to create safety cultures in complex healthcare organizations and to reduce the incidence of errors. Many organizations are looking to informatics technology to help manage these complex safety issues by using smart technologies that provide knowledge access to users and automated safety checks and that improve communication processes. Harrison (2016) stated that “as nurse leaders in a clinical setting where smart tools are leveraged to increase the quality and safety of patient care, we have certain responsibilities to ensure safe implementation, training, and monitoring” (p. 21). To best utilize the available technology, nurse leaders and administrators must be able to use data. More and more graduate programs for nursing administrators are realizing the need for these emerging nursing leaders to be skilled in nursing informatics. These leaders must be able to use data, information, and knowledge efficiently and effectively to assess and manage their clinical settings and, ultimately, to apply these informatics skills to improve patient outcomes and the quality of patient care (Figure 15-2).
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