Groups target alarm fatigue at hospitals

Accrediting panel finds problem worsening

By Liz Kowalczyk
Globe Staff / April 18, 2011

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The national organization that accredits hospitals will tackle the failure of medical staff to respond to patient alarms, making it a top priority this year. The decision follows a growing number of instances in which desensitized nurses didn’t hear or ignored beeping monitors warning that a patient was in trouble.

“There is uniform agreement that this is a major problem’’ that appears to be worsening, Dr. Paul Schyve, a senior vice president at the Joint Commission, said in a telephone interview. The Illinois organization has decided that the issue, referred to as alarm fatigue, will be one of a small number it focuses on in 2011, and it plans to meet with Food and Drug Administration officials and pinpoint a strategy over the next few months, he said.

The FDA said Friday that it already has been discussing with two industry groups the development of “a strategic approach’’ to alarm fatigue.

These decisions come two months after a Boston Globe investigation identified at least 216 deaths nationwide between January 2005 and June 2010 linked to alarms on patient monitors that track heart function, breathing, and other vital signs. In many cases, 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 Globe based its numbers on an analysis of an FDA database of problems involving medical devices. Because the health care industry fails to report many cases, some believe the number of deaths actually is far higher.

In Massachusetts, the Globe identified at least 15 alarm-related deaths in the past six years.

In one case, at UMass Memorial Medical Center in Worcester, nurses failed to respond to an alarm that sounded for about 75 minutes, signaling that a patient’s heart monitor battery needed to be replaced. The battery died, so when the patient’s heart failed, no crisis alarm sounded.

In another instance at Massachusetts General Hospital last year, an elderly man suffered a fatal heart attack while the crisis alarm on his cardiac monitor was turned off and staff did not respond to numerous lower-level alarms warning of a low heart rate. Nurses told state investigators they had become desensitized to the alarms.

“If you have that many alarms going off all the time, they lose their ability to work as an alarm,’’ Schyve said.

The Joint Commission, an industry-supported nonprofit organization that inspects health care facilities and holds them to standards, issued an urgent alert in 2002 about alarms, after finding that 23 patients died or became comatose because their ventilators malfunctioned. In most cases, staff didn’t respond to alarms warning that machines were malfunctioning, set alarms incorrectly, or didn’t hear alarms set at low volume.

In 2004, the commission decided to make improving alarm safety part of its national patient safety goals, which signaled it was a high priority. However, the agency soon dropped the goal, thinking that hospitals had solved the problem.

But since then, hospitals have purchased many more monitors, and studies show that the vast majority of the alarms that sound are false, triggered by a patient moving or coughing, not a change in condition.

Schyve said the problem is far more complicated now than it was a decade ago, because manufacturers have “put a lot more alarms’’ on devices. In some intensive care units, he said, devices now sound alarms not only when a patient’s heart rate has gone above or below a set danger point, but also if the heart rate is headed in the wrong direction, whether or not it is a life-threatening situation.

He wouldn’t release numbers, but Schyve said the Joint Commission is getting more reports of hospital staff not responding to crucial alarms, or alarms being shut off.

He said the commission could make alarm safety a national patient safety goal again, or issue a special alert advising of immediate specific action, or take some other step.

First, he said, the organization has to nail down specific solutions; some health care industry experts said manufacturers must improve monitor design to sharply reduce false alarms, while others believe hospitals should hire more nurses.

Many hospitals respond to alarm incidents by putting nurses through extra training, but Dr. Peter Pronovost, director of the Quality & Safety Research Group at Johns Hopkins Hospital in Baltimore, said “telling nurses and doctors to be more careful and reeducating them isn’t the solution.’’

“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,’’ Pronovost said.

The Association for the Advancement of Medical Instrumentation, a nonprofit education organization run by the health care industry, has decided to make alarm safety its top priority for 2011. President Mary Logan said, “We don’t know enough yet to know if alarm safety is a design issue.’’

In a statement to the Globe, the FDA said it is in discussion with the instrumentation association and the ECRI Institute, a nonprofit health care research organization that analyzed the FDA data for the Globe, “on raising the awareness of these issues and challenging the industry and the Joint Commission to work with us on a strategic approach moving forward.’’

“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,’’ Schyve said. “Neither side alone is going to be able to figure out how to address this problem.’’

Liz Kowalczyk can be reached at

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