According to patient safety experts, the recently released report of the death of a heart patient at Boston's Massachusetts General Hospital in January shines a light on a national problem known as "alarm fatigue." Although intended to enhance patient safety, the typical cacophony of beeps and buzzes linked to patient monitoring devices in hospitals can lead healthcare workers to ultimately tune the noise out or even off, both of which investigators say occurred in the MGH case, reports the Boston Globe.
According to the report, 10 nurses could not recall hearing the beeps at the central nurses' station or seeing scrolling tickertape messages on three hallway signs that would have warned them as a patient's heart rate fell and finally stopped over a 20-minute span, reports the Globe. A separate bedside monitor was also turned off inadvertently.
MGH has taken several steps to correct the problem, including increasing the number of speakers in patient units, stationing additional nurses to monitor alarms and disabling off switches on patient monitoring devices. The hospital has also formed a committee that is reviewing the guidelines for placing patients on monitors in the first place, to see whether it is possible to monitor fewer patients and thereby reduce noise and alarm fatigue, Jeanette Ives Erickson, the hospital's chief nurse, told the Globe.
Alarm fatigue is not unique to MGH and is a symptom of a larger problem in human factors engineering, noted Paul Levy, CEO of Beth Israel Deaconess Medical Center in his blog, Running a Hospital. "As in other complex settings like power plants, safety systems are often added in response to sentinel events that have occurred or because of regulatory concerns. But the addition of safety systems carries the risk that those systems themselves cause new safety problems to arise," he wrote, adding that perhaps Don Berwick will be able to steer The Centers for Medicare & Medicaid Services toward some solutions.