2nd Potential Alarm Fatigue Death in 4 Years in Boston Area Hospitals

‘Alarm fatigue’ a factor in 2d death

by Liz Kowalczyk

The second patient death in four years involving “alarm fatigue’’ at UMass Memorial Medical Center has pushed the hospital to intensify efforts to prevent nurses from tuning out monitor warning alarms.

Nurses exposed to a cacophony of beeps may no longer hear them or begin to ignore them, and that’s what appears to have happened in the latest case: A 60-year-old man died in an intensive care unit after alarms signaling a fast heart rate and potential breathing problems went unanswered for nearly an hour, according to state investigators who reviewed records at the hospital.

The death occurred in August 2010 but was not reported to the state Department of Public Health until this spring. The state cited various violations by the hospital, including not responding to alarms “in a timely manner.’’

The fatality was remarkably similar to another at the Worcester teaching hospital four years ago, when nurses didn’t hear or ignored alarms indicating that the battery on an elderly woman’s monitor needed to be replaced. After the battery failed, 77-year-old Madeline Warner suffered cardiac arrest and the alarm didn’t sound.

Warner’s death in 2007 led the hospital to adopt aggressive measures to improve nurses’ responses and tackle alarm fatigue, which can occur when nurses hear alarms – many of them false – all day long. But the new death shows the problem continues, as it does at hospitals nationwide. It has led to at least 200 patient deaths since 2005 and likely hundreds more, according to a Globe investigation published earlier this year.

“I don’t think any hospital has fully solved this problem,’’ said Maria Cvach, an assistant director of nursing at Johns Hopkins Hospital in Baltimore and a specialists on alarm fatigue. At Hopkins, which is known for its intense focus on reducing false alarms and alarm fatigue, Cvach said she still sees nurses “not hearing or not answering alarms’’ because “they go off all the time.’’

Executives at UMass Memorial declined to comment about the latest death. The Globe obtained the Department of Public Health report on the case through a freedom of information request. The document does not say who disclosed the death to the state or provide a reason for the reporting delay, but the Globe’s stories on alarm fatigue, which included an account of Warner’s death, appeared several weeks before the health department was called.

The state inspectors’ report, which omits the patient’s name and other identifying details, indicates that the patient also was the apparent victim of a medication error. It does not make clear the extent to which that error or alarm fatigue contributed to the patient’s death.

The patient had been cutting down a tree and was struck in the head with a large branch in July 2010, breaking bones in his face and causing bleeding in his brain. After surgery at UMass Memorial, the patient was often restless and agitated. He kept removing a monitor that measured whether his blood had enough oxygen, triggering an alarm to sound much of one day – which could have been a factor in desensitizing nurses.

Read the entire article at Boston.com