Through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified issues relating to telemetry provision.
Telemetry describes heart monitoring using a wireless transmitter that displays the patient’s heart rhythm and electrical activity at a central nurses’ station but may not display it at the patient’s bed side. Telemetry allows more freedom of patient movement and is used more frequently in step‐down areas, so may be used in areas where the patient is not visible to staff. Appropriate supervision and oversight of telemetry systems ensure heart irregularities can be quickly identified and appropriately managed to prevent patient deterioration.
Identified patient safety issues relating to telemetry included variation in the practical management of systems, such as replacement of batteries, mapping the patient’s location, and setting patient specific parameters for telemetry monitoring to reduce the number of unnecessary alarms.
Following liaison with the British Cardiovascular Society and the British Heart Rhythm Society (BHRS), the BHRS developed Standards for continuous cardiac monitoring in‐hospital (telemetry). These standards support organisations to meet safety requirements for patients requiring cardiac telemetry, such as when cardiac telemetry may not be indicated, recording and documentation requirements and how organisations should audit telemetry systems.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.
A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.