In response to an inquiry, analysts from the Pennsylvania Patient Safety Authority queried the Authority's reporting system database for event reports of patient deaths related to physiologic alarm monitoring from June 2004 through December 2010. Using the keywords alarm, monitor, ECG [electrocardiogram], telemetry, pulse-ox, and defibrillator in combination with intensive care unit or telemetry unit, where death was mentioned or harm score signified death (i.e., "I"), staff identified 187 reports. Thirty five of the event reports indicated that patient death was related to some aspect of physiologic alarm management. The 35 event reports referenced the following types of monitoring equipment: (1) Blood pressure machine (n =1); (2) Bilevel positive airway pressure machines (n = 2); (3) Ventilators (n = 4); (4) Telemetry monitors (n = 28) The reports were categorized as either equipment (n = 4) or human (n = 31) failures.
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