ECRI PSO issues caution on cardiac monitoring ID

The ECRI Institute Patient Safety Organization (PSO) recently issued a warning about a patient safety issue involving cardiac monitoring of incorrect patients. The issue was brought to ECRI Institute PSO's attention in its analysis of reports submitted by participating healthcare providers.

ECRI Institute PSO reviewed numerous reports of cardiac monitoring of the wrong patients resulting in the deaths of unmonitored patients who experienced critical arrhythmias, says Clinical Director Karen Zimmer, MD.

"Ensuring positive identification of patients is a challenge in all healthcare settings," she says. "Reports submitted to patient safety organizations can help raise awareness of undetected risks occurring in hospitals and healthcare systems."

Zimmer says the potential for identification errors is significant in acute care settings, where a wide range of interventions are delivered in multiple locations by numerous staff who work in shifts. The extent of harm to patients caused by misidentification is unknown.

Although this problem is being seen in a cardiac monitoring situation, this caution applies to more situations throughout the healthcare system, she says.

The patient safety alert can be found online at