Healthcare News & Insights

Hospital takes aim at alarm fatigue after two patient deaths


After two cases of patients dying in part due to nurses ignoring their alarms, a Boston-area hospital is taking action.  A 60-year-old man died at UMass Memorial Medical Center after the alarms indicating his heart rate had sped up and his breathing was irregular went unheard and/or ignored for almost an hour. The patient died in August 2010, but the circumstances of his death were only reported to authorities a few months ago. This is the second such case at the hospital since 2007.

Officials with the state Department of Public Health indicated so-called “alarm fatigue,” when overwhelmed staff tune out alarms — which are often false alarms — may have played a role in the deaths.

A subsequent investigation showed the patient was restless and frequently removed his monitors in his sleep, which led to his monitors making false alarms for a large part of the day. He also received a too-large dose of a medication meant to relieve anxiety. It’s unclear how much of a role the medication error played in his death.

In the earlier case, nurses didn’t respond to an alarm indicating that the battery on a monitor needed to be replaced. Eventually, the patient went into cardiac arrest, the monitor failed to sound the alarm, and the patient died.

After the ’07 case, hospital officials enacted new procedures to reduce instances of alarm fatigue, but as with most other hospitals, it’s clearly still an issue.

Hospital officials didn’t release a statement about this most recent case, but did reiterate to state officials that it’s working to improve patient care and staff attentiveness to alarms.

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  1. Note that the word “overwhelmed” is used to describe the situation in nursing. This incident is a symptom of a much more complex problem relating to the health of the nation’s healthcare delivery “system” (but, calling it a “system” is probably a mischaracterization. “Systems” should be coordinated, stable and efficient). As budgets become tighter and pressure is increased to reduce costs, is it really a surprize that adverse events occur? Until the public and government recognize that the healthcare system is in crisis, and they start discussing fiscal health of the hospitals in their communities, more such events are predictable. No excuse for ignoring alarms, but let’s take a look at the root causes of the issue.