Today at Children's Hospital: Monitoring the Monitors

Time of event: 17:40

Hunter (my 13-month old daughter, twin of Brighton) awakened crying and immediately began triggering both Resp and SpO2 alarms, dipping into the 60s on SpO2. No nursing response for 15 minutes. I didn’t need a nurse’s response because I could observe that these fluctuations were due to poor sensor readings. But without my bedside presence Hunter, at a minimum, would have lay crying for 15 minutes. Worst case, the alarm would have been real and she would not have been discovered for 10 or 15 minutes, enough to cause death or brain damage.

And where was the nurse? On her meal break, with the other nurses failing to cover her responsibilities and not responding to alarms.

Tip of the Day for Parents: If you must have gaps in your bedside presence, try to time them to minimize the risk of inattention. The highest risk times are nights and weekends and during nurse breaks. You may want to ask when your nurse will be taking his or her meal breaks and coordinate accordingly. Asking them this also will highlight that you are aware of the tendency for the ball to get dropped during these times.

Why is this important? Medical errors kill tens of thousands of people every year in hospitals and we’ll never know how many of these are due to chronic inattention by nursing staff. The only way to avoid this particular cause of problems is to personally intervene and report incidents that occur as a result.

OBSERVE - INTERVENE - REPORT