At Hospitals, Patient Alarms Often Ignored

Sept. 23, 2011— -- The death of a 60-year-old patient at UMass Memorial Medical Center raised the alarm on a problem plaguing hospitals nationwide: the many medical machines that beep for attention.

The man, whose name has not been released, died in August 2010 after alarms signaling possible heart and breathing problems went unanswered for nearly an hour, the Boston Globe reported. His death is the second blamed on so-called alarm fatigue at the Worcester, Mass., hospital in four years.

"Simply adding alarms doesn't make the system safer," said Dr. Richard Cook, a critical care physician and safety expert at the University of Chicago Medical Center. "In fact, it can make it less safe because there are so many false alarms that people end up not being able to figure out which ones are important."

Alarm fatigue, also dubbed the "cry wolf" phenomenon, is a growing problem in a health care system increasingly reliant on machines. A stroll down a typical hospital hallway offers a chorus of beeps and buzzers, most of which require no action by hospital staff.

"Each box, each device, each program is claiming the attention of the human operator. The result is people are confronted with many, many alarms, only a few of which are meaningful or important," Cook said. "The function of the human becomes to ignore alarms. And inevitably some get ignored that would have been important to pay attention to."

Cases such as the one at UMass often evoke a wave a finger-pointing. But Cook said nurses and doctors can't be blamed for missing alarms.

"The current approach is to immediately try to figure out who goofed," he said. "But it's a pervasive problem in the health care system and it's only getting worse."

Device manufacturers need to include sensitive, loud alarms to protect themselves from liability. What ensues is an "arms race for attention," a term coined by David Woods in 1985 to describe the emerging problem in heavily automated factories, commercial aircraft flight decks and power plant control rooms.

"One of the major problems associated with the Three Mile Island meltdown was that so many alarms were going off in the control room, it was impossible for the operators to form a clear understanding of what was happening," Cook said, referring to the 1979 accident at Three Mile Island nuclear plant in Dauphin County, Pa.

Ironically, TMI is now slang for "too much information."

The patient deaths at UMass Memorial are just two of many. Between 2005 and 2008, there were 566 alarm-related deaths in the United States, according to the FDA's Manufacturer and User Facility Device Experience database.

"The problem is not limited to a particular hospital," said Maria Cvach, a registered nurse and assistant director of nursing, clinical standards, at Johns Hopkins Hospital in Baltimore. "This problem has been around for a very long time all over the country."

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."