At Hospitals, Patient Alarms Often Ignored


The Search for Solutions to an Alarming Problem

Finding a solution to the alarm problem, Cvach said, will take cooperation from the people who make medical devices and the hospitals that use them.

"Every alarm should be viewed as an important alarm," which could mean raising the threshold or applying a delay to avoid drawing attention to meaningless fluctuations in measurements, like blood oxygen levels, she said. "It sounds counterintuitive to apply a delay, but it actually makes it safer because you're giving truer, more meaningful information."

Cvach and more than 250 other health care professionals and device manufacturers from will convene next month in Herndon, Va., for a medical device alarms summit hosted by the Association for the Advancement of Medical Instrumentation.

"The issue of alarms hasn't really been addressed in a systematic way," AAMI president Mary Logan said. "People like to bash the FDA because they're not being hard enough on device companies or nurses because they're not paying attention to alarms. But the issue can't be resolved by any one person working alone. It's a system problem."

But for families who have lost loved ones to alarm failures or other hospital errors, it's hard to accept there's no one to blame.

"It's always sad when you have to hear another story like this. It's sad for the family and it's sad for the nurses and doctors," said Sorrel King, whose 18-month-old daughter, Josie ,died because of a communication breakdown at Johns Hopkins Hospital 10 years ago. With the settlement from Josie's case, King created the Josie King Foundation with a simple mission: "To prevent patients from being harmed or killed by medical errors."

"This wasn't supposed to happen; no one wanted this to happen," King said of the death at UMass Memorial. "It just shows we've got a long way to go in improving patient safety and reducing medical errors."

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