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Hundreds of patient deaths blamed on "alarm fatigue"

The failure of hospital staff to respond to alarms from medical devices contributes to many patient deaths. A Boston Globe investigative report linked over 200 hospital patient deaths between January 2005 June 2010 to problems with alarms on machines that monitor patients' vital signs.

The medical devices do not malfunction in many cases, but the patient dies because hospital staff members fail to respond to a device's monitor in a timely manner.

Although device monitors can help save lives by alerting nurses and doctors that a patient could be in trouble, the increased use of monitors creates a phenomenon called "alarm fatigue" in which medical personnel become desensitized to the persistent beeps of monitors.

Nurses sometimes ignore alarms for dying device batteries or for non-urgent problems. The habit of ignoring alarms makes it harder for the nurses to recognize and respond to urgent alarms. The staff of a 15-bed hospital unit documented an average of 942 alarms per day, which was about 1 critical alarm every 90 seconds.

A medical device manufacturer reported that nurses at one hospital silenced urgent alarms from the manufacturer's cardiac monitor. The monitor allegedly sent 19 dangerous-arrhythmia alarms over nearly two hours, which went unheeded. The patient died, said the manufacturer.

Another patient at the Massachusetts General Hospital had a heart attack while the crisis alarm on his cardiac monitor was disabled. The hospital's nurse staff failed to respond to numerous lower-level alarms that warned of the patient's low heart rate and none of the nurses recalled hearing the beeps that sounded at the nurse's station. The nurses also failed to see the scrolling messages on three hallway screens which broadcasted warnings about the patient's lowering heart rate.

The patient's heart rate fell over a period of 20 minutes and finally stopped.

The Boston Globe was able to identify 15 recent patient deaths related to missed alarms or problems with monitors. At least 7 of the cases involved dying batteries or disconnected cables and 13 of the cases involved cardiac monitors.

The FDA requires device manufacturers to investigate reported deaths but manufacturers usually conclude that their monitors worked properly and attribute patient deaths to hospital staff members who misprogram or ignore the monitors.

A medical consulting firm said that the manufacturers are to blame for monitor fatigue because the devices are so sensitive that alarms sound when patients shift in bed or cough. There are studies which indicate that over 85 percent of device alarms are false.

The FDA has yet to require monitor design changes to prevent alarm fatigue and there is a concern that any device changes could lead to new problems.

Source: Boston Globe, "Alarm fatigue blamed in hospital deaths," Liz Kowalczyk, 2/13/2011

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