Nonprofit Raises Alarms about Patient Safety

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April 18, 2011; Source: Boston Globe | If stories about air traffic controllers sleeping on the job don't cause you worry, here's one that might keep you awake at night. A nonprofit group is warning that action is needed to address the problem of "desensitized" medical staff failing to respond to alarms in hospitals that signal when patients might be in trouble.

“There is uniform agreement that this is a major problem’’ getting worse, says Dr. Paul Schyve, a senior vice president at the Joint Commission, the Illinois-based nonprofit group that accredits hospitals nationwide. Called “alarm fatigue,” the issue is also being scrutinized by the Food and Drug Administration (FDA), which is exploring strategies for remedying this problem.

A Boston Globe investigation attributed at least 216 deaths nationwide between January 2005 and June 2010 to failure of medical personnel in hospitals to react to “alarms on patient monitors that track heart function, breathing, and other vital signs.” The Globe found many instances in which “medical personnel didn’t react with urgency or didn’t notice the alarm, a type of desensitization that occurs from hearing alarms — many of them false — all day long.”

The Joint Commission has been raising alarms about this problem since 2002. Dr. Shyve says the problem has worsened from the growing use of monitors in hospitals, some of which can be triggered when a patient isn’t in trouble, but has just moved or coughed.

“In the ICU there is somewhere between 50 and 100 electronic pieces of equipment, and each of them has alarms. Each individual device maker makes its alarms the most annoying. It’s an arms race of alarms. No one has worked on integrating them. The FDA could require that all these monitors link into a common platform,’’ said Dr. Peter Pronovost, director of the Quality & Safety Research Group at Johns Hopkins Hospital in Baltimore.

The Globe says the FDA it is talking with groups that represent instrument makers and organizations, including the Joint Commission, focused on health safety to work with the agency to develop a strategy. “Sooner or later, there is going to have to be a meeting with the users of alarms and people who put the alarms on their equipment,’’ Dr. Schyve said. “Neither side alone is going to be able to figure out how to address this problem.’’ – Bruce Trachtenberg

  • David Estrada

    I would like to echo the concerns about alarms, especially on the overnight shifts when there isn’t necessarily a nursing supervisor. These patients are vulnerable and deserve the best care possible. It’s common sense and the medical staff has a duty to respond immediately to an alarm.