The death of a patient at Massachusetts General Hospital last month, after a heart monitor was turned off, has sparked an internal investigation by the hospital, and brings to light a growing nationwide problem with regards to critical alarms either not working or being ignored or turned off altogether, endangering the lives of patients.
The patient already was "in crisis" when a nurse making a routine check made the discovery, reports the Boston Globe. Jeanette Ives Erickson, MGH's chief nurse, said the patient's monitor could have been turned off during another patient crisis, with the understanding that the alarm merely had been paused.
Such a situation, though, is exactly why research and consulting firm the ECRI Institute--which focuses particularly on medical devices--placed "alarms on patient monitoring devices" as the No. 2 health technology hazard entering this year. For instance, 12 percent of the nearly 2,200 medical device problems reported to ECRI between 2000 and 2006 had to do with alarms.
Kathryn Pelczarski, director of ECRI's applied solutions group, pointed to a condition that inadvertently causes nurses and physicians to tune out alarms known as "alarm fatigue" as another major problem. "There may be so many alarms going off it sort of becomes the background noise," Pelczarski said. "We have seen situations where all the nurses are responsible for all the alarms within that unit and there is the assumption that someone else will get that alarm."
Pelczarski also noted that she's heard of situations where alarms have been "turned down to the point of being inaudible." The Joint Commission's George Mills said that he is aware of similar situations that occurred earlier this decade where alarms had been covered with gauze and tape to stifle any potential noises made.
Despite such incidents, Dr. Lucian Leape, who specializes in medical safety for the Harvard School of Public Health, is curious as to why such devices even have an off switch in the first place. "[H]ow come there are devices where this is possible?" he asked.
Dr. Gregg Meyer, senior vice president for quality and patient safety at MGH, said it was likely that nurses were busy with other patients, hence the reason for the delayed response time to the patient.
To learn more about this growing problem:
- read this Boston Globe piece
- check out this ECRI press release
- here's a Sentinel Event Alert from the Joint Commission from 2002 on faulty alarms