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Cases & Commentaries
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Hildy Schell-Chaple, RN, PhD; September 2019
After undergoing a scheduled percutaneous coronary intervention, a man with a femoral sheath still in place was admitted to the medical ward, where several beds had recently been converted to cardiac telemetry beds. Having limited experience with femoral sheaths, the nurse removed it but was unable to assess the patient every 15 minutes as required due to becoming busy with another patient. One hour later, the patient was unresponsive, a code was called, and he was transferred to the intensive care unit where he died several hours later.
Journal Article > Review
Bach TA, Berglund L, Turk E. BMJ Open Qual. 2018;7:e000202.
Alarm fatigue limits the utility of physiologic monitoring devices intended to keep hospitalized patients safe. The authors conducted a literature review and interviewed experts to identify best practices to optimize device alarms. They present a step-by-step guide to alarm improvement that incorporates a human factors engineering approach.