By Federal investigators recently concluded that alarm fatigue was a factor in the death of a cardiac patient at Massachusetts General Hospital in January.
The patient’s heart rate gradually declined, then stopped, over a 20-minute period, but none of the 10 nurses on duty that morning recalled hearing the alarms or seeing the scrolling alarm messages on three hallway signs. While alarms are designed to draw attention to patient problems, they go off so frequently that healthcare staff tend to tune them out after awhile. Call it “the boy who cried wolf” syndrome.
The ECRI institute, a research institute based in Pennsylvania that specializes in medical devices, listed alarms on patient monitoring devices as the number two hazard on its top 10 list of health technology hazards.
Nurses at Johns Hopkins Hospital recently conducted a quality improvement initiative to decrease alarm fatigue and improve patient care. A key component of the initiative was tailoring alarm parameters to individual patients — an intervention that eventually led to a 40% reduction in critical care alarms.
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