Patient dies after heart monitor alarm goes unheard

A 70-year-old man underwent lung decortications followed by a weeklong stay in the surgical intensive care unit and subsequent transfer to a telemetry floor.

Three days later, he was found in his room unresponsive and with no pulse or spontaneous breathing. EKG strips in the records showed that his cardiac arrest began at 11:25 a.m. However, the code blue flow chart showed that the resuscitation effort did not begin until 11:34 a.m.

The record does not contain any explanation for the nine-minute delay. A code blue was called and the patient was eventually resuscitated and moved to the ICU. His condition deteriorated, however, and he died 10 days later, never having regained consciousness. An autopsy showed that he had suffered extensive acute anoxic changes to multiple organs.

The family was given conflicting information as to what occurred at the time of the cardiac arrest. Initially they were told by one of his treating physicians that the heart monitor alarm had failed to sound and that no one knew how long he had been in arrest before he was found.

After an investigation was conducted by the hospital, the family was told that: all systems were checked and found to be in working order; alarms went off as appropriate; the nurse on duty was in the medicine room and did not hear the alarm; and a nurse’s aide in an adjoining wing was “not trained” for bell recognition.

The patient’s family claimed that the volume of the alarm had been lowered to a virtually inaudible level and that the hospital didn’t have a policy in place for maintaining the alarm volume.

The hospital’s experts were prepared to testify that based upon the EKG strips, there was at most an approximately two-minute delay from the cardiac arrest to the time that chest compressions were started.  They were also planning to testify that the patient was in precarious health with severe coronary artery disease prior to his surgery and immediately after surgery. In addition, they were planning to testify that his overall status was poor and his life expectancy appeared extremely limited prior to the date of the incident.

The case ended in a $950,000 settlement.

Type of action: Medical malpractice

Injuries alleged: Death

Date: Jan. 25, 2010

Submitted by: Ralph F. Sbrogna and Roger J. Brunelle, Sbrogna & Brunelle, Worcester

(for the patient)