Noticed a recent event on a medsurge where a patient was reported to be in 3rd degree heart block. The nurse of the patient was notified by CMU at the end of her shift that her patient in room xx had a rythm change to 3rd degree heart block.. The Md was notified, the patient was soon seen by the md and was ordered a cardio consult. It was soon discovered that the name was screwed up on the tele monitor where they had the wrong room number but the right patient being monitored. So long story short, cmu reported on the wrong patient. Turns out the patient being reported on was not on tele monitoring. The cardic consult was cancelled. But the real patient (who happens to belong to another nurse) was not identified/ treated until the name mix up was discovered. I was just wondering who was at fault?
Jan 15, '13
Whoever admitted the pt to tele should have verified the name was correct. However, at my hospital we are supposed to verify the correct pt is on tele with the correct tele box number if on a portable monitor. So, anyone taking care of him that did not check is also guilty.
Jan 16, '13
Just like the previous post, we also have to identify the tele box with the correct patient every shift, and enter it into the computer charting system so that this does not happen. I don't know how this could have been prevented otherwise.
Jan 17, '13
No harm, no foul, but the staff should take it as a cautionary tale to be more careful in the future.
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