As tragic as the Boston case was, it was an incident that could have occurred at almost any hospital in the country: Investigators from the Centers for Medicare & Medicaid Services found that an audible alarm on a cardiac patient’s bedside monitor had been turned off the night before. When a medical crisis occurred, no one responded promptly—and the patient died.
Ten nurses were on duty on the patient’s floor at the 883-bed Massachusetts General Hospital on a January morning when the alarm should have gone off. But even if it did, it would have been one of the hundreds of alarms that medical personnel encounter when doing their jobs every day. So while this case of alarm fatigue drew a big media spotlight, it also created a virtual line in the sand that most hospitals will have to cross sooner or later.
The ECRI Institute, in its 2010 Top 10 Technology Hazards, cited “alarm hazards” as “among the problems most frequently reported” to the organization and ranked it No. 2 as a hazard. It noted that the variety of equipment with alarms—including patient monitoring equipment, ventilators, and dialysis units—were considerable.
To address alarm fatigue, it is “important to take a holistic view of the problem,” says Gregg Meyer, MD, MGH’s senior vice president for quality and patient safety. “People expect when a loved one comes to the hospital that they will be closely observed and monitored appropriately ... [and that] any signals from those monitors will be responded to.
“I think that’s a very reasonable request on one hand,” Meyer says. “But on the other hand, when you put that into the context of a busy inpatient unit, it gets complicated very, very quickly.”
For MGH, this meant going back and asking the simple questions, such as: Does this patient need to be monitored? After sorting through guidelines compiled by professional organizations, “we found that we were maybe overmonitoring people,” he says.
And it meant evaluating how loud the alarms should be—and finding some middle ground. “If you want your alarm to be heard, the answer is ‘yes,’” when it comes to loudness, Meyer says. But if you’re a patient, “Do you want to be woken up at night, or kept awake by another patient’s monitor? The answer is ‘no.’”
This led to coming up with new solutions—for example, adding more speakers across a ward and possibly directly routing monitoring alarms to beepers or cell phones of staffers. In ICUs, “the cacophony of alarms?from ventilators to cardiac monitors to other machines—was really quite something to sort out,” he said.
“And at the end of the day, how can we ensure that we have these reasonable signal-to-noise ratios?” Meyer asks. “The reality of it is that no matter how attentive you are, all of us will experience some level of fatigue. And that fatigue comes from our brain constantly working to try to separate out what are the important signals from what is just the background.”