Healthcare News & Insights

Growing problem: ‘Alarm fatigue’ blamed in patient fatality

All the alarms in the world can’t protect a patient in crisis if the people monitoring those alarms ignore or turn them off. That’s the hard lesson recently learned at Massachusetts General Hospital. A new report from the Centers for Medicare and Medicaid Services (CMS) indicates that 10 nurses on duty that morning didn’t remember hearing the beeping alarms or seeing the scrolling messages at the central monitoring station the morning a patient died in January.

An additional monitor at the patient’s bedside had been turned off the night before by an unidentified person.

The patient, who was not identified in the report, was in the hospital following surgery. The patient had a history of cardiac problems and was waiting for implantation of a pacemaker. An investigation into the death showed that the patient was active early in the morning, until his/her heart rate started to fall at 9:53 a.m.

Since no one noticed the central alarms, and the bedside monitor was turned off, no one checked on the patient until 10:16 a.m., when a nurse entered for a routine test.

By then, the patient was unresponsive.

In response to the incident, Mass General has disabled the off switches on alarms, assigned a nurse specifically to monitor alarms at the central station and installed more speakers so nurses can hear alarms even when not at the station.

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Comments

  1. heather says:

    In the SNF i work for, the “bells and whistles” are constantly going off. This sometimes lasts for more than 5-10mins. It’s sort of like signage. People are “immune” to the over signage and alarms nowadays. The reason is common sense…too much too often becomes back drop. Think about the car alarms blaring over and over for indefinite periods of time, all going unnoticed by the OWNERS. So the rest of us have learned to tune them out for our own sanity. MASS GENERAL did the obvious remedy: hire a person strictly to monitor such things!!! wow!! what a novel idea.

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  1. […] certainly is never the only cause of adverse events, it’s a leading factor in many of them, as demonstrated by numerous studies.  Besides increasing the risk to patients, the Alert noted that it puts health care workers’ […]

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