Nursing

Patient deaths aim spotlight on urgency for monitor technician training

Nurse Leader Weekly, November 20, 2003

Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!

Patient deaths aim spotlight on urgency for monitor technician training

Nurses and other employees at Martin Luther King Jr./Drew Medical Center, Los Angeles, CA, botched the care of two women, who died there this summer, failing in one case to notice that a patient's heart had slowed and stopped for over 45 minutes, according to a recent state report.


Inspectors from the California Department of Health Services found that nurses at the medical center failed to adequately examine patients and that some apparently had never been taught to use new bedside monitors. In addition, one nurse lied about performing crucial tests ordered by a doctor, the report said.


In both cases, a technician assigned to watch a central monitor displaying patients' vital signs was also given other duties. It is unclear if anyone was watching the monitor when the technician was away or when the women needed emergency attention, state health inspectors said.


Los Angeles County, which owns King/Drew, has reassigned the technician while it conducts its own investigation and has changed the rules so monitor technicians may do nothing but watch the monitors. County officials also reported a nurse to the state nursing board for documenting care that was not provided to one of the women, said Laura Sarff, director of quality improvement for the county Department of Health Services.


Since the women's deaths, July 4 and July 15, the county's investigation has focused largely on potential problems with a new monitoring system that was installed in late June. In September, hospital officials disconnected the $411,000 system, in part because nurses said that they were worried it wasn't reliable and that it hadn't alerted them to the two women's distress. The state report did not address whether the system itself failed, but raised questions about the staff's training and mistakes made in using the monitors.


In one case, an incorrect identification code was entered into the computer, meaning the patient's vital signs did not show up on the central monitoring system. As a result, the central alarm didn't sound when her condition changed, staff members told the state inspectors.


After the deaths, county officials said they had introduced additional training for the staff on using the monitors and the need to both perform and document procedures ordered for patients.


The state report does not carry any immediate penalties for the hospital, but county officials must quickly draft and implement a plan to correct the violations. Inspectors have the option of requesting a full-blown survey of the hospital's problems by the U.S. Centers for Medicare and Medicaid Services, which could lead to sanctions against the hospital, including loss of federal funds.


Adapted from: The Los Angeles Times.



Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!

Most Popular

Related Articles