Description of Event or Problem · 1
DATE OF EVENT: THIS PROBLEM HAS BEEN OCCURRING REPEATEDLY FOR OVER 12 MONTHS. GE HEALTHCARE CIC PROTM CLINICAL INFORMATION CENTER SOFTWARE VERSIONS (B) (4) AND (B) (4). AT (B) (6) HOSPITAL, THERE ARE GE CARDIAC MONITORS ON COMBINED NURSING UNITS GE CARDIAC ICU AND TELEMETRY ON ONE FLOOR WITH NEURO ICU AND TELEMETRY ON ANOTHER FLOOR, WHERE WE ARE CONTINUING TO HAVE ISSUES THAT CREATE AN UNSAFE PATIENT SITUATION. PATIENT BEDS ARE ASSIGNED AND LOCKED IN SPECIFIED ORDER ON CENTRAL CARDIAC DISPLAY MONITORS -CIC PROTM CLINICAL INFORMATION CENTER- WITH RESPECTIVE PATIENT WINDOWS TO DISPLAY CARDIAC RHYTHMS, PRESSURE WAVEFORMS, AND VITAL SIGNS FOR EACH PATIENT. IN THESE COMBINED PATIENT CARE UNITS, THE MONITORS IN EACH PATIENT ROOM ARE REFERRED TO AS COMBO MONITORS BECAUSE THERE IS THE CAPACITY TO MONITOR EITHER THROUGH THE ICU HARDWARE BEDSIDE MONITOR OR TO USE TELEMETRY MONITORING. THE EXPECTATION OF THE CARDIAC DISPLAY MONITOR AT THE NURSES DESKS IS THAT THE PATIENT WINDOW FOR EACH PATIENT ROOM IS LOCKED IN PLACE AT ALL TIMES. THESE AT TIMES HAVE BECOME UNLOCKED. WHEN THIS HAS HAPPENED, THE PATIENT WINDOW COULD BE REMOVED OR REPLACED WITH ANOTHER PATIENT WINDOW. THIS IS A PATIENT SAFETY ISSUE BECAUSE THERE HAVE BEEN INSTANCES WHEN A PATIENT WINDOW HAS BEEN REMOVED FROM THE CENTRAL DISPLAY MONITOR, A PATIENT WAS ADMITTED TO THE ICU MONITOR -SOLAR 8000I- OR A TELEMETRY PACK APEX PRO FH. BUT, NURSING WAS NOT ABLE TO VIEW THE CARDIAC RHYTHM AT THE CENTRAL DISPLAY. THERE ARE OTHER ISSUES WE HAVE EXPERIENCED RELATED TO CIC/CENTRAL STATION MONITORING WITH THE USE OF COMBO BEDS, WHERE BOTH ICU AND TELEMETRY MONITORING ARE AVAILABLE, THAT REQUIRE MANUAL CORRECTION ON SOMETIMES A DAILY BASIS. WHEN PATIENTS ARE TRANSFERRED OR ADMITTED TO COMBO BEDS FOR TELEMETRY MONITORING, SOMETIMES THE COMMUNICATION BETWEEN THE ICU MONITOR AND TELEMETRY MONITORING SEPARATES. WHAT THIS MEANS IS THAT TELEMETRY IS VIEWED IN ONE PATIENT WINDOW AND ICU PATIENT MONITORING IS VIEWED IN ANOTHER PATIENT WINDOW FOR THE SAME BED. THIS CREATES A PATIENT SAFETY ISSUE BECAUSE THE CIC DOES NOT ALWAYS DISPLAY THE 2ND WINDOW, WHICH COULD INCLUDE THE CARDIAC RHYTHM. AND IF THERE IS AN OPEN/UNLOCKED PATIENT WINDOW, THAT 2ND VIEW IS DISPLAYED THERE AND LOCKS AUTOMATICALLY INTO THE WINDOW. THERE ARE ADDITIONAL CENTRAL CARDIAC DISPLAY MONITORS WITHIN THESE NURSING UNITS WHERE PATIENT WINDOWS ARE TO REMAIN UNLOCKED AND OPEN SO NURSING CAN VIEW ANY PATIENT AT ANY TIME. HOWEVER, THESE HAVE BECOME LOCKED, ALTHOUGH THEY SHOULD ONLY BE ABLE TO BE LOCKED WITH A PASSWORD THAT NURSING DOES NOT HAVE ACCESS TO. IN ADDITION TO THESE PROBLEMS, WE CONTINUE TO HAVE MESSAGES IN THE CARDIAC MONITORS READING FINO DEVICE MASTERFL WITH LETTERS -ATS- AND NUMBERS 7, 8, OR 9 FOLLOWING THIS MESSAGE. THIS MESSAGE IS DISPLAYED ACROSS THE TOP OF ALL CARDIAC MONITORS THROUGHOUT THE HOSPITAL. THESE MESSAGES APPEAR MULTIPLE TIMES PER DAY, EVERY DAY. THIS HAS BEEN REPORTED TO GE AND SOME WORK HAS BEEN DONE BY GE ON SITE, BUT THE MESSAGES CONTINUE. GE HAS TOLD US THAT WE ARE WITHIN CAPACITY OF THE CARDIAC MONITORING SYSTEM ON THESE COMBINED NURSING UNITS, WHERE ICU HARD WIRE SOLAR AND TELEMETRY ARE BOTH USED. THESE ISSUES HAVE OCCURRED ON TWO DIFFERENT NURSING UNITS THAT ARE COMBINED ICU AND TELEMETRY MONITORING, ALTHOUGH THE MAJORITY OF THE OCCURRENCES HAVE BEEN ON ONE PATIENT CARE UNIT WITH A GREATER VOLUME OF TELEMETRY MONITORING. GE HAS PULLED LOGS FROM THE COMPUTERS FOR ALL OF THESE CARDIAC MONITORS AND CAN SHOW THAT THESE INSTANCES HAVE NOT BEEN OPERATOR INITIATED OR OPERATOR ERRORS. THESE HAVE OCCURRED DUE TO A SOFTWARE LIMITATION. WE ALSO HAVE DOCUMENTATION OF THIS OCCURRING AT ONE OF THE OTHER HEALTHEAST HOSPITALS IN THE ICU/TELEMETRY NURSING UNIT. THESE PARTICULAR PROBLEMS HAVE BEEN GOING ON FOR 18 MONTHS THAT WE ARE AWARE OF. IN (B) (6) 2009, I BEGAN DOCUMENTATION OF INCIDENTS OF LOCKED INAPPROPRIATELY OR UNLOCKED INAPPROPRIATELY, TO CONVEY TO GE THE ONGOING SIGNIFICANCE OF WHAT WE FELT WAS A PATIENT SAFETY ISSUE. GE BEGAN WEEKLY PHONE CONFERENCE CALLS WITH US IN NOVEMBER OF 2009 TO BE APPRISED OF THE LOCK/UNLOCK EVENTS, THAT CONTINUED TO OCCUR AS OFTEN AS DAILY. IN JANUARY, GE SENT AN ENGINEER AND CLINICAL APPLICATION SPECIALIST ON SITE AT (B) (6). THEY PULLED COMPUTER LOGS FROM CIC'S AND WERE ON SITE TWO DAYS OBSERVING THE EVENTS. SINCE THAT VISIT, WE WERE INFORMED BY GE THAT THEY WERE ABLE TO REPLICATE ALL SCENARIOS IN THE LAB, INCLUDING LOCK/UNLOCK PROBLEM. ALL DATA COLLECTED FROM THE SITE VISIT WAS STUDIED AND GE HAS NOT BEEN ABLE TO DETERMINE ROOT CAUSE AT THIS POINT. IN MARCH 2010, GE ENGINEERING HAS CALLED IN A LARGER GROUP OF ENGINEERS TO MEET AND DETERMINE WHAT THE NEXT STEPS WILL BE TO IDENTIFY THE ROOT CAUSE. AS OF MAY 5, 2010, GE HAS NOT REPORTED TO US THE ROOT CAUSE OR PROVIDED US WITH A SOLUTION TO THE SOFTWARE LIMITATION. WHEN PATIENT WINDOWS BECOME UNLOCKED OR LOCKED INAPPROPRIATELY, IT CREATES AN UNSAFE PATIENT SITUATION. THIS SITUATION IS NOT READILY IDENTIFIABLE, BUT MUST BE DELIBERATELY ASSESSED FOR. AT THIS TIME, THE ONLY RESOLUTION IDENTIFIED, IS THE SAME AS WE HAVE BEEN DOING, AND THAT IS TO MANUALLY ENTER THE SERVICE MODE AND LOCK OR UNLOCK THE SLOTS WHEN IT HAPPENS. HEALTHEAST MET WITH GE MEDICAL ON MAY 18, 2010 AT WHICH TIME GE OFFERED US A TEMPORARY SOLUTION TO THE LOCKING ISSUE, WHILE PLACING MORE URGENCY ON LOOKING FOR SOLUTIONS TO BOTH THE UNLOCKING ISSUE AND THE SEPARATING/SPLITTING ISSUE.