An investigation by the newspaper shows that over 200 U.S. hospital patient fatalities between January 2005 and June 2010 are linked to problems with alarms on patient monitors that track heart function, breathing, and other vital signs.
Generally, the issue isn’t the equipment, but rather the failure by medical personnel to react with urgency or notice the alarm. As monitor use continues to rise, the sounds produced by the machines can sometimes occur with such frequency that nurses become desensitized. How frequent do these alarms sound? At a 15-bed unit at Johns Hopkins Hospital in Baltimore, staff documented an average of 942 alarms per day – about 1 critical alarm every 90 seconds.
In addition, the devices themselves have flaws that contribute to alarm fatigue. For example, monitors can be so sensitive that alarms go off when patients sit up, turn over or cough. Some studies have found more than 85 percent of alarms are false (i.e. they go off when the patient isn’t in danger. Over time this can make nurses less and less likely to respond urgently to the sound.
In many cases, of course, nurses miss alarms warning of problems that aren’t life-threatening. But even the highest-level crisis alarms, which are typically faster and higher-pitched, also may go unheeded.
In one extreme case, a cardiac monitor blared 19 dangerous arrhythmia alarms for nearly 2 hours before staff silenced the alarms temporarily without treating the patient, who died. In other instances, staff have misprogrammed complicated monitors or forgotten to turn them on.
Hospitals that have experienced alarm-related deaths have aggressively addressed the issue, hiring nurses and technicians whose sole job is to monitor the monitors and modifying monitors to make them less sensitive to unimportant changes and less prone to false alarms. But overall, hospitals and the medical device industry have yet to seriously tackle the issue.
Patrick Malone is a leading consumer safety advocate and trial lawyer based in Washington, D.C. The injury & malpractice attorneys at Patrick Malone & Associates help victims of medical malpractice and other serious personal injuries obtain justice in the courts of Washington, D.C., Maryland and Virginia.
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