1. Events – time line Death at the intensive care at the heart clinic
Source: Final report RO 2013:02
Death at the intensive care ward N25 at the thorax clinic at Karolinska University Hospital in Solna, Stockholm, October 17, 2010

2. The hospital stay at THIVA (Thorax Intensive Care)
Heart patient arrived on Oct. 11 for surgery
The patient had surgery on Oct. 12 as planned and also received a pacemaker
The patient got cardiac arrest on Oct. 13
Lack of space occurred at THIVA on Oct. 16
A decision was taken on Oct. 16 to move the patient to the ward N25 as a satellite patient
Reporting by telephone to the ward N25
A current summary of the care course was written in the patient’s care journal

3. Hospital stay at the ward N25
Assistant nurse Ka received a report about the patient
The workload increased at 20:00-20:30
The night staff started working at 21:00
A night nurse, N1, received the task of following a worried patient to X-ray
THIVA moved the patient to N25 shortly after 21:00
Assistant nurse Ka received the patient in the room 9
Assistant nurse Kb helped to enter the patient into the monitoring equipment, telemetry
The box ”patient with pacemaker” was not ticked when entering data into the telemetry

4. Hospital stay at the ward N25
The responsibility for the patient was transferred between nurses: K1 – N1 – N2
Nurse K1 informed nurse N1 and N2 that the patient suffered from nausea
Nurse K1 ended her/his evening shift at 21:30
Nurse N1 went to the X-ray with the worried patient
Nurse N2 visited the patient during the evening. The patient received drugs for nausea.
Two red alarms from the monitoring with telemetry at 23:01 and 23:04. (TAKY)
Nurse N1 returned to the ward at approx. 24:00

5. Hospital stay at the ward N25
Nurse N1 and N2 visited together the patient who found it difficult to breathe. The pacemaker was discovered in the bed.
Nurse N1 informed the primary call who referred to the call at THIVA. No contact was made.
Two red alarms at 0:42 (TAKY)
Two red alarms at 0:56 and 0:58 (TAKY)
Approx. at nurse N1 and N2 visited the patient.
A red alarm from the patient at 01:00 (TAKY)
A yellow alarm at 01:04 (SHORT VT)

6. Hospital stay at the ward N25
Nurse N1 was at the nursing expedition and read patient journals
Nurse N1 went to the patient at approx. 02:30 and the patient was found lifeless
Cardiopulmonary rescue was conducted. ECV waveform was written.
The patient was declared dead at 02:56
The telemetry was turned off and erased