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Unheard and Ignored Hospital Patient Alarms Lead to Unnecessary Deaths

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February 18, 2011

A news investigation has found that hundreds of patients have died in hospitals when the alarm on their monitoring equipment went unheard or unheeded.

Hospitals use a number of monitoring devices with patients, designed to alert hospital staff in the event of a life-threatening emergency. From alarms that sound when equipment has a low battery or a patient gets out of bed to those that monitor heart arrhythmias, hospital units can experience hundreds of alarms each shift.

The Boston Globe has found that a shocking number of patients have died in hospitals from the improper use of patient monitoring equipment, the disregard of monitoring alarms by hospital personnel and a conditioning known as “alarm fatigue.”

According to a video released in January 2011, the U.S. Food and Drug Administration (FDA) received 566 reports of patient deaths related to alarms on monitoring devices between 2005 and 2008.

The Boston Globe had ECRI Institute, a nonprofit healthcare industry research and consulting organization, review data from the FDA’s adverse event database for patient deaths in which problems with monitor alarms occurred. Researchers found that more than 200 deaths between January 2005 and June 2010 where related to problems with alarms equipment monitoring patient’s heart, breathing or other vital signs. ECRI believes that the actual number of cases is likely far higher because the healthcare industry underreports these types of events to regulators.

Very few of the cases resulted from malfunction of the equipment. Sometimes, the alarms had been silenced, the volume turned low or the equipment otherwise misused. In other cases, hospital staff claimed they did not hear the alarm.

The article cited one case in which a patient died after a cardiac monitor sounded at least 19 alarms for a patient’s arrhythmia over the course of two hours, but hospital staff at the nursing station silenced the alarms without providing any care to the patient.

Alarm fatigue can occur when hospital staff repeatedly hear alarms, especially false or low priority alarms, and become desensitized to the sound and the urgency of the situation.

In April of 2010, the Boston Globe featured the story of a patient who died due to alarm fatigue of the hospital staff.

The FDA warns that adverse incidences related to monitoring alarms can be compounded by several other factors, including that the alarms are easy to disable or silenced, easy to overlook that alarm is turned off or personnel can be unfamiliar with equipment.

The FDA recommends:

  • Don’t silence alarms without first checking on the patient
  • Make sure that all patient alarms are appropriately activated and not suspended
  • That the alarm volume is high enough to be heard outside the patient’s room

Hospital staff should perform these checks when assuming care of a patient from colleagues, after shift changes and after the transfer of patients. Hospitals should also ensure all staff, even traveling and float nurses, are trained on the equipment and become familiar with all monitor functions, especially disrhythmia alarms, screen icons and meanings of different alarm sounds.