Investigation Finds Hospital Staff Not Responding to Medical Alarms

Some 216 hospital deaths nationwide are being linked to problems with alarms on patient monitors and medical staff failing to respond, found a Boston Globe investigation.

The Globe analyzed the Food and Drug Administration’s database of adverse events involving medical devices from January 2005 to June 2010.

In many cases, the problem wasn’t defective medical alarms. The medical industry calls the problem, “alarm fatigue.” Hospitals are using more medical alarms than ever to monitor patients, all of which have different sounds and speeds depending on the severity of the physical symptom.

In one case, a 15-bed unit at John Hopkins Hospital in Baltimore, staff documented an average of 942 alarms per day – about one critical alarm every 90 seconds.

The result, hospital administrators say, is nurses have become desensitized to the constant beeping. And patient safety advocates say their medical negligence is resulting in patients suffering wrongful deaths, including in Massachusetts hospitals.

“Hospitals must establish a “zero tolerance” for patient injuries or deaths due to alarm errors or so-called “alarm fatigue,” according to Boston medical malpractice lawyer Marc Breakstone. “These devices save lives. They not only have to work, but the staff has to respond immediately when they sound. Anything less is unacceptable.”

One case dates back to September 2008 at Tobey Hospital in Wareham. An 87-year-old man was wearing a wireless heart monitor that started to weaken. He later died and a state investigation found his EKG displayed a flat line on a monitor at the nurses’ station for over two hours without a response.

Cases of medical negligence such as these are driving change at Massachusetts hospitals.

Southcoast Health System, which manages Tobey Hospital, is hiring nurses and giving them one assignment: responding and monitoring patient monitors. It has also established a policy that monitor batteries must be changed at a certain time each day.

At UMass Memorial Medical Center in Worcester, the hospital wants to eliminate unnecessary monitoring and has implemented new guidelines for when doctors should order cardiac monitoring. Among other changes, nurses are now receiving low-battery warnings about patients on their pagers and cell phones.

As hospitals make these changes, manufacturers are assessing their equipment and working on new “smart monitor” technology. Rather than measure just one symptom, the hope is these new monitors would assess multiple parts of the body before determining whether an alarm needs to sound. For its part, the Food and Drug Administration recently distributed videos about defective medical alarms and proper use to 4,500 hospitals and nursing homes.
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