‘Alarm fatigue’ a factor in 2d death

UMass hospital cited for violations

September 21, 2011|By Liz Kowalczyk, Globe Staff
(Page 3 of 3)

Other hospitals have found alarm fatigue to be a stubborn problem, despite their best efforts to reduce it.

A study at Hopkins, led by Cvach in 2007, documented an average of 942 serious alarms per day - about one critical alarm every 90 seconds - on one 15-bed unit. Other studies have found that more than 85 percent of alarms are false, meaning the patient is not in any danger.

Hopkins has been trying to eliminate false alarms caused by patient movement and by slight changes in a patient’s condition that don’t require additional care.

It reduced alarms on one unit from 300 per patient per day to 100 per patient per day, Cvach said. But “even if there are 100 alarms per patient per day and a nurse has three patients, that’s still a lot of alarms a nurse has to deal with,’’ she said. “We still haven’t conquered the problem.’’

Like many nurses and doctors, Cvach believes one key solution is better machines, which take into account multiple measures of a patient’s health - heart rate, respiratory rate, blood pressure, and blood oxygen level - to more accurately gauge whether a patient is really in crisis before an alarm sounds.

Theresa Gallivan, associate chief nurse at Massachusetts General Hospital, said monitor makers need to improve their products.

Following an alarm fatigue-related death at Mass. General last year, which was first reported by the Globe, the hospital has overhauled its system for monitoring patients.

“Do we have the perfect system that has cracked the code on this? Absolutely not,’’ Gallivan said. “There is such a mismatch of technology and what we are trying to achieve.’’

Liz Kowalczyk can be reached at kowalczyk@globe.com.

Advertisement
Advertisement
|
|
|
|