A brief analysis of telemetry–related events.

Review

A brief analysis of telemetry–related events.

January 14, 2020

Kukielka E, Gipson KR, Jones R. Patient Saf. 2019;1(2):36–44.

Reliable telemetry monitoring reduces the potential for rare yet catastrophic patient harm. Drawing from 4 years of data submitted to the Patient Safety Authority reporting system, this article documents factors involved in errors related to the use of telemetry which include battery problems, improper alarm use and communication issues. It highlights training and development of procedures and protocols that align with the practice environment as strategies for improvement.

Available at

Free full text (PDF)

Related Resources From the Same Author(s)

Medication safety in the emergency department: a study of serious medication errors reported by 101 hospitals from 2011 to 2020.

March 30, 2022

Process failures that increase the risk of infection through respiratory droplets: a study of patient safety events reported by hospitals across Pennsylvania.

October 7, 2020

Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy.

February 5, 2020

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.

March 24, 2021

Comparing the evolution of risk culture in radiation oncology, aviation, and nuclear power.

December 9, 2020

Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey.

April 12, 2023

2017 John M. Eisenberg Patient Safety and Quality Awards.

July 18, 2018

Risk and Event Assessment.

August 4, 2010

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022.

November 16, 2022

Patient Safety and Quality.

March 3, 2010

Resident Duty Hours Across Borders: An International Perspective.

January 21, 2015

Hospital internet site content on patient safety and medical errors.

September 27, 2006

Measured response to identified suicide risk and violence: what you need to know about psychiatric patient safety.

June 1, 2005

The star of the diagnostic journey: assessing patient perspectives.

November 28, 2018

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

October 6, 2021

2018 John M. Eisenberg Patient Safety and Quality Awards.

July 17, 2019

Engagement of leadership in quality improvement initiatives: executive quality improvement survey results.

July 11, 2007

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good Catch" awards.

August 1, 2012

Reducing inappropriate polypharmacy in primary care through pharmacy-led interventions.

January 22, 2020

A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its meetings.

August 4, 2010

Exploring vulnerability to patient safety events along the age continuum.

April 3, 2019

Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients?

January 8, 2020

Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits.

May 11, 2016

Patient Safety.

August 19, 2020

Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family.

June 1, 2022

Noah's story: please listen.

May 2, 2012

The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review.

March 8, 2023

The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program.

April 13, 2022

Debriefing for patient safety.

November 26, 2008

Is incivility an underlying threat to safety in obstetrics?

February 18, 2015

Chief resident indirect supervision in training safety study: is a chief resident general surgery service safe for patients?

September 1, 2021

Family involvement in managing medications of older patients across transitions of care: a systematic review.

June 26, 2019

Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care?

September 11, 2019

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics.

March 8, 2023

Impact of medical education on patient safety: finding the signal through the noise.

February 8, 2023

Applying thematic synthesis to interpretation and commentary in epidemiological studies: identifying what contributes to successful interventions to promote hand hygiene in patient care.

September 9, 2020

Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions.

July 13, 2022

Second Annual Nursing Leadership Congress: "Building the Foundation for a Culture of Safety" conference proceedings.

June 20, 2007

Lessons from the war on cancer: the need for basic research on safety.

May 11, 2005

Patient Safety.

May 1, 2019

Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals.

June 29, 2022

Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study.

August 11, 2021

Focus on the Quadruple Aim: development of a resiliency center to promote faculty and staff wellness initiatives.

June 6, 2018

2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database.

May 19, 2021

Daily check-in for safety: from best practice to common practice.

October 26, 2011

Patient safety and legal regulations: a total-scale analysis of the scientific literature.

October 19, 2022

The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events.

July 7, 2021

Psychometric properties of the perinatal missed care survey and missed care during labor and birth.

January 19, 2022

Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports.

July 13, 2022

Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database.

July 6, 2022

Preventing medication errors in pediatric anesthesia: a systematic scoping review.

November 9, 2022

Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.

September 14, 2011

Patient safety practices: leaders can turn barriers into accelerators.

May 11, 2005

The patient perspective on errors in cancer care: results of a cross-sectional survey.

December 1, 2019

Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.

October 26, 2022

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

October 27, 2021

We are not there yet: a qualitative system probing study of a hospital rapid response system.

April 20, 2022

Teamwork before and during COVID-19: the good, the same, and the ugly….

August 24, 2022

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg.

June 15, 2022

Health Care Equity

January 31, 2024

Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications.

May 11, 2005

Lessons learned from a death outside a hospital's doorstep.

June 26, 2019

Report focuses on risk to patients from ED errors.

October 30, 2019

Becoming a high-reliability organization through shared learning of safety events

January 22, 2020

Alcoholism and American healthcare: the case for a patient safety approach.

August 17, 2022

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system.

February 2, 2022

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.

November 30, 2022

Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology.

May 19, 2021

Medication reconciliation during hospitalization and in hospital-home interface: an observational retrospective study.

April 7, 2021

2009 John M. Eisenberg Patient Safety and Quality Awards.

November 25, 2009

The 2015 John M. Eisenberg Patient Safety and Quality Awards.

May 25, 2016

2012 John M. Eisenberg Patient Safety and Quality Awards.

May 29, 2013

The 2016 John M. Eisenberg Patient Safety and Quality Awards.

June 28, 2017

The 2013 John M. Eisenberg Patient Safety and Quality Awards.

April 30, 2014

Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection.

March 11, 2015

The 2021 John M. Eisenberg Patient Safety and Quality Awards.

August 3, 2022

The role of the electronic health record in patient safety events.

January 9, 2013

Using Six Sigma to improve patient safety in the perioperative process.

August 28, 2013

Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals

September 1, 2021

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre.

July 22, 2020

2008 John M. Eisenberg Patient Safety and Quality Awards.

October 8, 2008

American Hospital Association-McKesson Quest for Quality Prize.

October 11, 2006

2007 John M. Eisenberg Patient Safety and Quality Awards.

December 12, 2007

American Hospital Association-McKesson Quest for Quality Prize.

October 10, 2007

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

August 5, 2020

Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.

September 1, 2021

The role of automation in complex system failures.

May 11, 2005

Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention.

August 12, 2020

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

November 16, 2022

Pharmacy Education and Practice.

January 26, 2022

Development of a patient safety web-based education curriculum for physicians, nurses, and patients.

August 31, 2005

Improving Diagnosis.

November 28, 2018

How to reduce maternal mortality rates in the United States.

May 8, 2019

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Care management implementation and patient safety.

September 27, 2006

Does patient-centered design guarantee patient safety?: Using human factors engineering to find a balance between provider and patient needs.

November 30, 2005

Implementing and validating a comprehensive unit-based safety program.

May 11, 2005

Development of the ICU safety reporting system.

May 11, 2005

Child-specific risk factors and patient safety.

May 11, 2005

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis.

February 7, 2024

Nutrition Support Safety.

February 7, 2024

Common ECG interpretation software mistakes.

January 10, 2024

MRI safety: prepare for new guidance.

January 10, 2024

How does robotic-assisted surgery change OR safety culture?

September 6, 2023

American Geriatrics Society 2023 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

August 16, 2023

Guidelines on Human Factors in Critical Situations 2023.

August 9, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

A novel approach for assessing bias during team-based clinical decision-making.

June 14, 2023

Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update.

May 17, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment.

April 26, 2023

Journal Article

Study

A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics.

March 29, 2023

Patient Safety Innovations

Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes

March 29, 2023

The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review.

March 8, 2023

Interview

In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

December 14, 2022

Perspective

Resilient Healthcare and the Safety-I and Safety-II Frameworks

December 14, 2022

WebM&M Cases

Mechanical Prosthetic Valve Thrombosis with Thromboembolism.

November 16, 2022

Aligning patient safety and stewardship: a harm reduction strategy for children.

December 22, 2021

Patient harm from cardiovascular medications.

August 25, 2021

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies.

August 18, 2021

Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death.

August 11, 2021

Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment.

June 2, 2021

Adverse events among emergency department patients with cardiovascular conditions: a multicenter study.

March 10, 2021

Racial bias in pulse oximetry measurement.

December 20, 2020

Automation failures and patient safety.

December 2, 2020

Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer III Report.

September 2, 2020

WebM&M Cases

Nothing Called Small Surgery

August 26, 2020

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

See More About The Topic

Ambulatory Care

Quality and Safety Professionals

Cardiology

Device-Related Complications

Latent Errors