Sentinel Failures

What is a Telemedicine Emergency Failure?

Any handling of a patient experiencing an emergency, which is materially below the standard of care, is considered a telemedicine emergency failure.  Failures commonly result in delayed evaluation and treatment, no treatment, and improper evaluation and treatment.  

What is a Sentinel Event? 

A telemedicine sentinel event is a severe telemedicine failure in an accredited hospital facility.  Severe failures are those resulting in death, permanent harm, or severe temporary harm with intervention required to sustain life.  Psychiatric emergencies including suicidal thoughts is the leading type of emergency during telemedicine and suicide of a patient within 72 hours of discharge from a facility may be considered a sentinel event. 

How are Telemedicine Emergency Failures missed? 

Emergencies occuring during telemedicine are often poorly tracked and rarely properly handed off.  Since the patient is remote from the provider, delays are common and adverse events can be easier to miss.   The use of telemedicine makes it easier to continue the protocol of telling people on the line to “hang up and call 911.”  First responders may leave the scene if they do not quickly find the caller at the location provided.  This has resulted in telemedicine follow-up gaps that are greater than in-person care.  Providers are left wondering “what happened to that patient?”  For most facilities and practices, business continues. They rarely connect or attribute the patient’s death to the poor handling of an emergency during one of their telemedicine visits.  


Failure Type 1: List of EMS and 9-1-1 Administrative Phone Numbers and Fax

A large tele-primary care program created a database of emergency phone numbers covering all the addresses of their patients. Some were 9-1-1 administrative 10-digit numbers and some were direct ambulance company numbers Providers and managers were given the excel sheet and directed to ask the patient their current address and cal the corresponding number to the city or county. Here are some things that happened.

  1. When the doctor called the 9-1-1 admin number, the doctor’s address showed up on the screens. Some dispatches sent first responders to the address they receive as per 9-1-1 policy.
  2. At times they called these numbers and were placed on on-hold while dispatchers handled real 9-1-1 dialed emergencies
  3. At times they called the 9-1-1 dispatch and they no longer cover the area. 0-2% change, close, or open every 90 days.
  4. At times the ambulance company was called and states a 1 hour ‘transport time.’ Local ambulances are not always stationed with an average 8-12 min response time to all locations. 9-1-1 shuffles vendors to ensure coverage
  5. At times an ambulance number is called for a suicidal agitated patient. and police do not arrive with EMTs.
  6. NJ 911 The current NENA PSAP Directory contains information that was not provided by our office. Many New Jersey PSAP jurisdictions and contact numbers are not correct. None of the network transfer numbers appear in the directory as they can be dialed from anywhere and will not provide ANI/ALI information.’


Failure Type 2: Call the doctor’s local 9-1-1 and request transfer

For emergencies a large national telehealth company had their doctors call 9-1-1 from their local phone and request the call be transferred to the 9-1-1 dispatch servicing the address where the patient was located. Here are some things that happened.

  1. When the patient address was in a different state. the dispatcher did not have the technology to transfer.
  2. They had a patient in LA county when the doctor was located in Ventura county (2 hour drive). The doctor’s call was first transferred to the wrong dispatch center, then transferred again and again, but did finally reach the location. The process took 25 minutes.
  3. The doctor was rushing the emergency handoff. The doctor’s address (not the patient’s address) shows up on the 911 screens. The dispatcher did not understand the request but said they could handle the case. They sent a unit to the doctor’s address on the screen.
  4. A doctor called 9-1-1 and said she was calling on behalf of a patient in another area. She needed to be transferred. The police officer handling dispatch asked ‘Are you the person who is having an emergency?’ ‘Where are you located now?” The officer stated it is not their policy to transfer or send units to people who did not call 9-1-1 themselves. The officer instructed the doctor to have the patient call 9-1-1 themselves.


Failure Type 3: Intermediate Helper Staff

This method employs central staff to help providers coordinate telemedicine emergencies. Providers are given a phone number to call when there is an emergency for a staff member to help them. Staff members range from administrators with knowledge of emergency services to outsourced call centers who aid in all telehealth operations. Some of the reported failures include;

  1. Doctors have reported wait times over 15 minutes for staff to pick up and help them. Even if a call center is used as a backup. Doctors should test pickup times for when they call.
  2. Handoff content changes 10-20% with each additional intermediate. This is similar to playing the Broken Telephone Game. When the doctor hands off the case to the administrator staff, who hands off the case to 911 dispatchers and EMS, information is left out or changed.

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