missed an abnormal rhythm

[puffin75RN]

Hi, I frequently visit this forum and I was looking for a post on a similar topic but could not find one so I'd thought I'd share my experience. I will try to only include pertinent information. I work night shift on a telemetry unit and have been off orientation for about a month, long story short on a recent shift I messed up big time. I had a patient come from the ER with epigastric pain/chest pain and was to have a stress test in the am to rule out cardiac problems. I was told by ER nurse patient was in NSR on the monitor and on EKG, had no previous cardiac history, caridac enzymes negative. Pt came up to me early in the shift, they were asymptomatic. I printed out a strip of NSR, however it was only showing on one lead, my first mistake; my second mistake was throwing that strip away because it was only on one lead. I fixed the lead a few hours later. Pt's HR and vitals were stable throughout the night, pt asymptomatic during the night. I was watching the monitor, which shows a small window of the rhythm with all the other pt's rhythms. From this view pt's rhythm appeared to be in NSR, HR was normal throughout the night. I messed up by not looking at monitor events during the evening; we are supposed to check the monitor during our shift, but because the monitor wasn't alarming to any abnormal rhythm I did not think any abnormal rhythms would be occurring. I know how bad of an assumption this is.

Well come morning the day nurse looks at a full screen monitor of events and it shows the pt having pauses in her rhythm all night, did an EKG and notified cardiology, dr determined pt was in a 2:1 heart block; when the doctor looked at EKG and monitor history he wasn't concerned, apparently he has known her to be in this rhythm on previous visits? But I was freaking out because I couldn't believe I didn't realize my patient was in this rhythm all night. The other nurses agreed I dropped the ball. I feel like such a failure as a nurse for neglecting to check the monitor. I know I have learned not to make this mistake again. I was just wondering how often something like this happens and what the consequences are for the nurse?

[Boomer MS, RN]

I cannot answer your last two questions but will chime in here. First of all, no harm was done, thank goodness. So going from there, you are learning. You are not a failure. From what you said, you are newly off orientation. If we all came into nursing with the experience and knowledge of a nurse who had been in practice for 30+ years, well, that would be a perfect world. Doesn't happen. Darn. So you've learned not to rely entirely on an alarm. Great! And even alarms can be faulty, looking like V-fib. Check the patient. And never assume anything. Do not be too hard on yourself, please.

[calivianya, BSN, RN]

I would say you've learned your lesson, so there won't be much condemnation here.

My workflow, just in case you find this helpful, is I print a strip for both of my patients first thing when I arrive and plot the strips right away, even if other things are happening, even if the strip is just in one lead. If I hear a call bell, I tell them just a minute and that I will be in after I glance at their initial paperwork. I make a mental note of what that strip looks like on the monitor, too, since the rhythm on the monitor looks a little different from what's actually printed on the strip sometimes. If I have low amplitude or a lot of artifact, I go in and change the leads and increase the amplitude with my first assessment, and print another strip.

I look at my patient's rhythm frequently throughout the night - mostly because both of my patients' monitors are displaying at my pod, unless I have a split pod, in which case I will sit at the pod with the sicker patient but walk at least once an hour to look at my other patient's rhythm.

With a new admission or transfer, the first time I walk out of the room for anything, even if it's just a bag of IVF, I stop by my pod and print a strip and at least look at it very closely, if I don't go ahead and plot it.

Hospitalized patients have changes in status frequently. You won't know if there are any changes if you don't plot the strip right away. Someone could have a rhythm change 15 minutes into my shift, but if I hadn't plotted the strip immediately after report, I wouldn't have necessarily caught the difference.

To be perfectly fair, 2:1 conduction can look a heck of a lot like NSR, especially if the first P wave is buried in the T wave, and especially if the patient is wiggly and the artifact makes the T waves look wonky anyway.

[nutella, MSN, RN]

I do not know about your facility policy but where I worked they had q2 or q4 h tele checks with measuring a strip and documenting in a book - if you work on a busy floor I suggest you set a timer on your phone - that way it will alarm and you won't forget!

[AJJKRN]

Maybe it's just me but why doesn't your facility not have a central monitoring room with monitor techs watching all Pt's on tele? (except ICU's and specialty units of course)

The biggest flag I would be concerned about would be the monitor not alarming, how do you know other staff on the unit didn't silence the alarms? No excuse for not checking the Pt's history throughout the night but this is my burning question.

Rhythms often take a while to be comfortable with. I got lucky and cross-trained as a monitor tech while working as a CNA during nursing school so for the most part I can just look at a strip or the screen and see what's going on. It will take time to get this good just like it will take time to get better at nursing in general. It's how we all grow!

Unless you act like you already know everything right out of the gates, as some new nurses act, your peers should have supported you with not only honesty but ways to grow and/or be more aware of your tele's.