NR 721 Week 4 Unintended Consequence Memo Example

Memorandum

To: Director of Clinical Engineering; Director of Nursing, Medical Services

From: Nurse Manager, 5 West Medical Unit

Date: 18 October 2027

Re: Telemetry transmitters lost since the discontinuation protocol began: 19 in 14 months, about $44,650, and what I will do by 1 November

The Effect, and How Long I Have Known

Since the nurse-driven telemetry discontinuation protocol began on 5 West on 12 August 2026, telemetry transmitters have gone missing far more often than before. Clinical engineering's asset log records 19 transmitters lost from the unit in the 14 months since, against 2 in the 12 months before. Clinical engineering first raised this with me in February 2027, eight months ago, when the count reached six. I acknowledged it then and did not act, because I expected the rate to settle once staff were used to the protocol. It has not settled, and I should have brought it to you sooner.

The Evidence Already Recorded

The figures come from records that other departments already keep. The asset log shows each transmitter's last scan at a charging station and its status. The 19 lost units were last scanned on 5 West and never returned; 4 were later mailed back by patients' families with a note saying the device had been found in a discharge bag. The purchasing record shows 15 replacement transmitters ordered for the unit since March 2027, at $2,350 each. The central monitoring station's log shows 23 leads-off alarms in September alone for transmitters assigned to patients who had already been discharged, which is how the technicians first noticed boxes leaving with patients.

How the Protocol Produced It

The mechanism is a change in who removes the transmitter and where. Before August 2026, telemetry was stopped by a provider's order, and the monitor technician called the unit to have the box returned, so removal usually happened in one place, with the box going straight back to the charging station. Under the protocol, the bedside nurse removes the box mid-shift, often during a medication pass, and all six charging stations stand in the supply room past the final patient room. In September's removals, the box was scanned back onto a station within an hour in only 23 of 40 cases. A box left on a bedside table is easily packed with a patient's belongings at discharge. The protocol did what it was meant to do, moving the decision to the nurse, and in doing so it moved the box's last stop from the station to the room.

Why It Was Not Foreseen

The protocol was designed around the clinical decision, which criteria justify stopping monitoring, and those criteria came directly from the national monitoring standards (Sandau et al., 2017). The design never treated the transmitter as an object with a route back to its station, because under the old process someone else handled that route. Removing a practice often shifts small, unwritten tasks onto people who were never told they now own them, and those tasks are where unintended effects tend to appear (Norton & Chambers, 2020). Nurses did not create a workaround here; they simply had no step for the box, and the box went where the patient went (Debono et al., 2013).

The Accounting

Table 1

Telemetry Transmitter Losses, 5 West

Note. Note. From clinical engineering's asset log and purchasing records. Returned units were cleaned and put back into service.

This is the cost side only. The protocol's benefit, about eight fewer telemetry days per 100 patient-days than before it began, is real and is weighed separately; this memo does not argue that the losses outweigh it. It argues that the losses are a side effect the unit created and can largely remove.

What I Will Do, and By When

I will make three changes, all within the unit's own authority, by 1 November 2027. First, a box return bin will be mounted at the nurses' station, midway along the corridor, so a removed transmitter can be dropped within a few steps of most rooms; clinical engineering has agreed to empty and scan it twice a day. Second, the removal documentation will gain a required line, "transmitter returned to bin or station," which the record team has agreed to add as a single checkbox. Third, the unit's discharge checklist will gain the line "telemetry transmitter removed and returned," checked by the discharging nurse.

What I Need From You

From clinical engineering, I need the twice-daily bin collection and a monthly count of transmitters lost from 5 West. From the Director of Nursing, I need agreement that the discharge checklist change can apply to the whole medical service if it works on 5 West, since float nurses will otherwise learn two checklists.

When I Will Report Back

I will report the November and December loss counts to both of you on 15 January 2028. If losses have not fallen to two or fewer a month by then, I will propose moving the charging stations themselves, which would cost about $1,800 in electrical work.

References

Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J. C., Black, D., Johnson, J., & Braithwaite, J. (2013). Nurses' workarounds in acute healthcare settings: A scoping review. BMC Health Services Research, 13, Article 175. https://doi.org/10.1186/1472-6963-13-175

Norton, W. E., & Chambers, D. A. (2020). Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Science, 15, Article 2. https://doi.org/10.1186/s13012-019-0960-9

Sandau, K. E., Funk, M., Auerbach, A., Barsness, G. W., Blum, K., Cvach, M., Lampert, R., May, J. L., McDaniel, G. M., Perez, M. V., Sendelbach, S., Sommargren, C. E., & Wang, P. J. (2017). Update to practice standards for electrocardiographic monitoring in hospital settings: A scientific statement from the American Heart Association. Circulation, 136(19), e273-e344. https://doi.org/10.1161/CIR.0000000000000527