California law requires hospitals to report certain events to the
Department of Public Health, which may issue administrative
penalties in certain cases. The California Hospital Association
maintains a database of those reports that elicited a penalty.
CHA members can access the database at www.calhospital.org/ij-catalog/reports.
One recent report involved a delay in detection of an arrhythmia
on a monitored patient due to the equipment being in standby
mode. In this telemetry unit, like many others, there was a
central station without bedside displays.
The system’s design makes communication to the telemetry
technician of a patient’s current status (e.g., “away for a
scan”) critical. As one manufacturer’s manual states: “Standby
suspends monitoring, and you won’t get any waveforms or alarms.”
If the technician does not know that a patient has returned from
a procedure or that a new patient has been admitted to a
previously empty “standby” bed, the lack of central monitoring
could be undetected by both the nurse and the technician.
CHPSO suggests that hospitals assess whether their telemetry
system has a similar vulnerability. In this particular report,
the hospital responded to the issue by putting in place a
structured communication protocol to improve communication
reliability and reduce the risk of an unmonitored event.
In their protocol:
Guidelines identify specific criteria for being placed in the
standby mode, which includes who notifies the technician when
patient leaves and returns to unit and for a documented projected
The telemetry technician will contact the assigned nurse to
determine the location and status of the patient if the patient
does not return by the projected time.
When handing off to the next telemetry technician, the
technicians will validate the patients who are on telemetry and
who are off for procedures and their projected return time.