“alarm fatigue.” Unheard and Ignored Hospital Patient Alarms Lead to Unnecessary Deaths

[The Straight Story]

Unheard and Ignored Hospital Patient Alarms Lead to Unnecessary Deaths


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 the U.S. Food and Drug Administration (FDA) received 566 reports of patient deaths related to alarms on monitoring devices between 2005 and 2008.

http://newyorkcity.injuryboard.com/medical-malpractice/unheard-and-ignored-hospital-patient-alarms-lead-to-unnecessary-deaths.aspx?googleid=288534

[KittyWampus]

1. 566 deaths over four years. Upsetting and tragic, especially for family members.

However, humans are only human. And nurses and hospital staff are not just human, they're over worked and under paid.

I wonder if those deaths were clustered in any particular hospitals.

And is it really possible to say that all those deaths were absolutely preventable even if someone had heeded the alarm?

[FarPoint]

3. I am most curious

How mant of these hospitals or clinical settings were staffed poorly due to Non-Union practice?

[Horse with no Name]

6. Well thanks to the California Nurses (UNION)

they pretty much set the standard of care in this country. They will strike for unsafe conditions, overstaffing etc.:patriot:

Not to say that the understaffing doesn't occur, because it absolutely does.

It used to be that you could refuse an assignment that you deemed unsafe. Now, in Texas, you cannot refuse that assignment, but you can invoke "Safe Harbor". What this does is file a petition that will be given to the State Board of Nursing and lay out your grievance as to why you feel your assignment was unsafe. This is in turn monitored for patterns and investigated by the State.
Of course, with Texas as a "Right to Work" state, invoking Safe Harbor will almost ALWAYS cost you your job--but it takes away the legal liability if something happens during your shift.

[Maine_Nurse]

11. Our non-union hospital has better staffing than the union one.

Just the way it is here.

[PoliticAverse]

2. I guess people didn't learn from car alarm 'fatigue'... n/t

[JVS]

4. Is this a corollary to car alarms or Kitty Genovese?

Or put more clearly. Are alarms ignored because people become insensitive to them and don't notice, or do they notice but since their job has them answering to alarms all day they think "let someone else get that one"?

[FarPoint]

9. Nursing sounds like

An abusive work environment ...when I visited a sick friend last week who was recovering from car accident ...I could feel the nurses stress....she seemed preoccupied, little time to talk and explain anything.

[Horse with no Name]

5. I got into a knock-down dragout argument with a Respiratory Therapist

over this issue.
In the days before we had what is known as "central monitoring"...which means the alarm rings at the desk as well as the room--we had bedside monitors. This meant you had to keep your ears open for alarms. As someone who checks out every alarm (exhausting), I kept hearing an alarm go off and would get up and when I got down the hall, it kept disappearing.
Finally, I tracked it down to a room with a 3 month old baby that had RSV. His oxygen levels were dropping.
Every time the alarm would beep, the mother silenced it. She was annoyed because it was keeping her awake.:eyes:
I asked her to not do that and explained to why it was going off.
Sometimes it is merely a nuisance, but in this baby's case, it was because his oxygen levels were dropping and that he needed to be suctioned.
The mother looked at me and was very hateful.
She said SHE needed her sleep and that the Respiratory Therapist UNDERSTOOD this and instructed her that if it beeped and had uneven lines to silence it. He also instructed her if the number was below 90, to INCREASE the oxygen. :wtf:
This was insane! I told the mother to leave the monitor alone and especially to leave the oxygen alone. I told her that if she increased the oxygen too fast or too high, even for a second, she could KILL her baby by expanding his lungs too quick. She didn't know this.
She did leave the monitor AND the oxygen alone after that.
I cornered the RT and told him to NEVER instruct my patient's parents to do this again.
Fortunately or unfortunately (I guess depending on the situation), the nurse is 100% responsible for what happens to their patient...even if the RT screws up, etc.

NOWADAYS though, this is not as much of a problem because bedside monitoring is almost obsolete and has been replaced by central monitoring.
The industry has known this and while this study is important, the problem in most instances has already been corrected. Thankfully.

[Maine_Nurse]

7. Oh central alarms aren't as prominent as many of us would like.

None around here except ICU's and cardiac units. The resp floor at the large medical center sounds like the slots room at a freaking casino. I am SOOOOOOO glad I don't work there. I honestly don't know how anyone can tell what is going on up there.

[Horse with no Name]

8. Oh yeah I know--but better than before.

We have them in ICU's, Peds, ER, and Cardiac.
This is actually one of the best systems I have ever seen. It is tied in to a main database and when the patient is transferred throughout the hospital from floor to floor, the data remains intact and goes with him to the new floor.

[PoliticAverse]

10. Interesting story. Thanks for posting it. n/t

[eilen]

12. There are too many alarms.

There is the IV pump alarms that go off the moment someone moves their arm, the telemetry alarm, the O2sat alarm.... and of course the call bells ringing. On top of that in the ED there are bells ringing constantly with overhead messages and people screaming at you all day. I honestly don't know how the nurses on the floor get their work done and documentation completed. Their director doesn't believe they need any help so these nurses work without techs or aides to help pt's to bedpans/bathrooms or even to help them turn a patient on the stretcher so they can change wet pads and sheets.

Whenever someone comes in that needs bipap-- occasionally a supervisor will send them to the floor which is crazy -- they belong on the critical care unit because the floors really are too understaffed for the charge nurse to adequately monitor them.