Power Failures During Surgery: A 2000-2019 Review of Reported Events in the Veterans Health Administration

Cardiac Telemetry Downtime and Contingency Plan Development: A Review of Downtime Events Reported in the Veterans Health Administration

BACKGROUND

Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety.

PROBLEM

Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime.

APPROACH

This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020.

OUTCOMES

Of 98 events, no patient harm was reported; 13% (n = 13) were planned downtime, 82% (n = 80) were unplanned downtime, 18% (n = 18) reported contingency plan use, 78% (n = 76) did not specify contingency plan use, and 32% (n = 31) reported events lasting 31 minutes to 6 hours in duration.

CONCLUSIONS

The majority of reported cardiac telemetry downtime events were unplanned and without documented contingency plans. A robust contingency plan with defined staff roles and responsibilities will serve to lessen anxiety during downtimes and mitigate potential risk of patient harm.