‘Alarm fatigue’ linked to patient’s death

US agency says monitors at MGH unheeded

By Liz Kowalczyk
Globe Staff / April 3, 2010

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Federal investigators concluded that “alarm fatigue’’ experienced by nurses working among constantly beeping monitors contributed to the death of a heart patient at Massachusetts General Hospital in January.

In a report released yesterday, the investigators said 10 nurses on duty that morning could not recall hearing the beeps at the central nurses’ station or seeing scrolling tickertape messages on three hallway signs that would have warned them as the patient’s heart rate fell and finally stopped over a 20-minute span.

Additionally, federal investigators said the volume for a separate audible crisis alarm on the patient’s bedside monitor was turned off the night before by an unknown person. Mass. General executives had previously told the Globe that this crisis alarm had been inadvertently turned off.

But investigators for the Centers for Medicare & Medicaid Services said that desensitization to alarms that actually sounded also was a factor in the patient’s death.

Mass. General executives said yesterday that they have taken numerous steps to correct the problems, including disabling the off switches for alarms on bedside cardiac monitors and that the federal Medicare program approved the hospital’s plan for addressing the issues.

Federal inspectors reviewed the case as part of a random routine inspection at the hospital from Feb. 2 to Feb. 16. They found additional problems during the visit as well, including locating video screens where visitors could see patients who were being monitored in their rooms.

Patient safety officials across the country have said the heart patient’s death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.

The ECRI Institute, a nonprofit research and consulting organization based in Pennsylvania that specializes in medical devices, listed alarms on patient monitoring devices as number two on its top 10 list of health technology hazards last year.

The Mass. General patient, whose name and age were removed from the federal report, had a history of heart problems and was in the hospital following surgery, awaiting implantation of a permanent pacemaker. On the morning in question, the patient ate breakfast, visited with family, walked around the unit, and took a bath, the report said. But at 9:53 a.m. the patient’s heart rate began falling, triggering the warning alarms. As it continued to plummet, the other crisis alarm did not sound because it was off.

A nurse did not enter the patient’s room until 10:16 a.m. for a routine test and discovered that the patient was unresponsive.

Federal inspectors found the hospital’s care of the patient deficient in a number of ways, but said Mass. General has corrected the problems through a variety of steps. In addition to disabling the off switches, the hospital has increased the number of speakers in patient units so nurses can hear alarms when they’re not at the central station. The hospital has also temporarily stationed nurses at central stations just to monitor alarms.

Jeanette Ives Erickson, the hospital’s chief nurse, said yesterday that Mass. General has formed a committee that is reviewing the guidelines for placing patients on monitors in the first place, to see if it is possible to monitor fewer patients and thereby reduce noise and alarm fatigue.

“If you went to any hospital floor in America where there is monitoring and asked the doctors and nurses, they would say there are too many alarms and too much background noise,’’ said Dr. Gregg Meyer, senior vice president for quality and patient safety.

Federal investigators also found dozens of other problems, or deficiencies, at the hospital, from violations of patient privacy to failure to respond to patient grievances quickly. It is typical to find dozens of violations of federal policy during inspections by the Medicare program, said Roseanne Pawelec, a spokeswoman for the federal agency.

“We are very tough on a hospital,’’ she said. “We look at every single aspect of their operations. It’s a grueling process for them. It’s also an eye-opener. Mass. General has been very responsive. They turned things around very quickly. They are literally in accordance with every [Medicare] standard for patient safety.’’

Patient privacy violations included white boards with patient names that were visible to other patients and to visitors and the use of closed-circuit surveillance cameras in patients’ rooms without consent. The camera monitors were at desks where visitors could see patients undressed or undergoing procedures.

In a summary of the issues, the hospital said that it has removed or relocated white boards containing patient information and that “video monitoring has been changed in several places to ensure that the image is accessible only to the appropriate people who are directly in front of the video monitor screen.’’

Medicare inspectors will return to the hospital for a routine follow-up visit within the next few months.

In an e-mail to employees yesterday, the hospital’s president, Dr. Peter Slavin, said Mass. General remains committed to “providing the highest-quality, safest care that meets or exceeds all standards set by external groups and our own internal standards.

“This recent survey is an opportunity to reexamine our policies, processes, and systems of care to ensure that we are providing the very best for our patients and families,’’ he said.

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