ECRI Institute PSO highlights patient safety issue involving cardiac monitoring errors in special E-lert

May 24 2011

In a recently released Patient Safety E-lert, the ECRI Institute Patient Safety Organization (PSO) highlights a patient safety issue involving cardiac monitoring of incorrect patients. The issue was brought to ECRI Institute PSO's attention in its analysis of reports submitted by participating healthcare providers. As part of its mission to research the best approaches to improving patient care, ECRI Institute is sharing this special E-lert with the healthcare community.

ECRI Institute PSO reviewed numerous reports of cardiac monitoring of the wrong patients resulting in the deaths of unmonitored patients who experienced critical arrhythmias.

"Ensuring positive identification of patients is a challenge in all healthcare settings," says Karen Zimmer, M.D., Clinical Director, ECRI Institute PSO. "Reports submitted to Patient Safety Organizations can help raise awareness of undetected risks occurring in hospitals and healthcare systems," Dr. Zimmer adds.

According to the E-lert, the potential for identification errors is significant in acute care settings, where a wide range of interventions are delivered in multiple locations by numerous staff who work in shifts. The extent of harm to patients caused by misidentification is unknown.

"Although this is being seen in a cardiac monitoring situation, this caution applies to more situations throughout the healthcare system. This advice should be applied to all systems where it has potential to occur," advises Barbara Rebold, RN, MS, CPHQ, Director of Operations, ECRI Institute PSO.

SOURCE ECRI Institute