A 69-year-old patient was in an intensive care unit and had already experienced one respiratory arrest, which was quickly treated. Nevertheless, the alarm on her vital sign monitor had been turned down. As a result, it could not be heard at the central nursing station and, in fact, could only be heard if the nurse was in the room and near the machine. The patient had a tracheostomy and could not call for assistance, and her call bell was not within reach. Monitor strips revealed that the patient experienced 30 minutes of a very low heart rate before a nurse came into her room and found that the patient was again in respiratory arrest. Even though she was resuscitated, this woman suffered a severe brain injury due to lack of oxygen from which she did not recover and eventually died.
Investigation revealed that the hospital had checked the monitor after this episode and found that it was in good working order. This led to questioning of the hospital staff who admitted that at the time of the patient’s respiratory arrest, the monitor’s audible alarms had been turned down or off, and the visible alarms could not be seen outside the room. After it was discovered that the monitors in the ICU had been turned off, resulting in the patient’s death, the hospital settled with her surviving family members for $1.65 million.
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