Minnesota Hospital Association

Quality & Patient Safety

April 01, 2005

Minnesota Adverse Health Event Alert

A telemetry device manufacturer had programmed a monitoring alarm function so it was in the “off” position and had not made this known to the hospital at the time of purchase. This “off” position prevents the alarm from signaling in the event of a low or failed battery or when the device’s leads become disconnected from the patient. An adverse patient outcome occurred when the unit’s alarm did not signal a problem and there was delay in treating a patient.

MHA recommends that all hospitals work closely with their clinical and biomedical staff and manufacturers of monitoring equipment to put systems in place to ensure that all alarm functions are appropriately programmed and used in the “on” position and are tested frequently to verify they are in the “on” position.

Based on information reported into the Patient Safety Registry, the Minnesota Hospital Association has worked with the members of MHA’s Patient Safety & Registry Advisory Council to prepare this alert. 

For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA patient safety registry manager, at japold@mnhospitals.org or (651) 641-1121 or toll free at (800) 462-5393.