In Estate of Mariah Edwards v. Abington Surgical Center (Montgomery County (PA) Common Pleas Court, the 17-year-old patient underwent a tonsillectomy in March 2012.

The plaintiffs, who were her parents, maintained she was left unattended, and that the monitoring equipment was either not working or not properly set. The teenager suffered respiratory distress after surgery.

By the time it was noticed, she was pulseless. She died 15 days later. The plaintiffs argued there was a failure to monitor after she received Fentanyl for pain.

The case was settled for $6 million.

Comment: Bleeding after a tonsillectomy is a known complication of this type of surgery.

The nurses in a post-surgical area in a same day surgery unit are expected to know this, to monitor the respiratory condition of the patient and keep alarms set on monitoring equipment. The Joint Commission published a Sentinel Event Alert on this subject on April 8, 2013.

They said many medical devices have alarm systems.

These alarm-equipped devices are essential to providing safe care to patients in many health care settings; clinicians depend on these devices for information they need to deliver appropriate care and to guide treatment decisions.

However, these devices present a multitude of challenges and opportunities for healthcare organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.

Read the full sentinel event alert here: Joint Commission SE on alarms

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