Cardiac monitoring enhances patient safety by alerting the caregiver to significant changes in the patient's cardiac status. But if the wrong patient is monitored, the late recognition of arrhythmias and delayed alarm response can lead to potentially avoidable deaths, according to an alert from ECRI Institute, a Plymouth Meeting, Pa.-based nonprofit that researches approaches to improving patient care.

The issue was brought to the attention of ECRI's Patient Safety Organization (PSO) in its analysis of reports submitted by participating healthcare providers, according to the institute.

"ECRI Institute's PSO has received reports of cardiac monitoring of the wrong patients, which resulted in the deaths of unmonitored patients who had experienced critical arrhythmias," ECRI stated.

Key contributing factors are:

• Lack of quality control checks, policies and procedures issues, lack of orientation or teaching;
• Communication failures, inadequate preparation, shift change, procedure not followed, inexperienced staff or lack of familiarity with procedure;
• Technology failures, distractions, instrument calibration and defective or unavailable supplies or equipment; and
• Physical assessment issues, protocol not followed, patient history not known.

"Healthcare facilities should establish mitigation strategies that include unique identifiers for each patient, particularly for patients with similar names. Telemetry receivers should incorporate a display screen with patient identifiers to reconcile the telemetry transceiver with the correct patient," ECRI stated.

ECRI's recommendations include:

1. Communication. Verify patient identification on admission to telemetry unit. Use systems that confirm that the correct receiver is used for the patient.
2. Responsibility delineation. Build in redundancies. Use two unique identifiers for each patient (e.g., name, birth date, identification number) for all critical processes: monitoring, diagnosis and medication use.
3. Development of alarm setting protocols. Cardiac monitoring central stations that display the heart rhythms of more than one patient should be labeled with the patients' identifiers, and a standardized method should be used by two staff members to reconcile each patient with the correct corresponding cardiac monitor at separate locations (bedside and telemetry receiver) to avoid confirmation bias.