The death occurred in August 2010 but was not reported to the state Department of Public Health until this spring. The state cited various violations by the hospital, including not responding to alarms “in a timely manner.’’
The fatality was remarkably similar to another at the Worcester teaching hospital four years ago, when nurses didn’t hear or ignored alarms indicating that the battery on an elderly woman’s monitor needed to be replaced. After the battery failed, 77-year-old Madeline Warner suffered cardiac arrest and the alarm didn’t sound.
Warner’s death in 2007 led the hospital to adopt aggressive measures to improve nurses’ responses and tackle alarm fatigue, which can occur when nurses hear alarms - many of them false - all day long. But the new death shows the problem continues, as it does at hospitals nationwide. It has led to at least 200 patient deaths since 2005 and likely hundreds more, according to a Globe investigation published earlier this year.
“I don’t think any hospital has fully solved this problem,’’ said Maria Cvach, an assistant director of nursing at Johns Hopkins Hospital in Baltimore and a specialists on alarm fatigue. At Hopkins, which is known for its intense focus on reducing false alarms and alarm fatigue, Cvach said she still sees nurses “not hearing or not answering alarms’’ because “they go off all the time.’’
Executives at UMass Memorial declined to comment about the latest death. The Globe obtained the Department of Public Health report on the case through a freedom of information request. The document does not say who disclosed the death to the state or provide a reason for the reporting delay, but the Globe’s stories on alarm fatigue, which included an account of Warner’s death, appeared several weeks before the health department was called.
The state inspectors’ report, which omits the patient’s name and other identifying details, indicates that the patient also was the apparent victim of a medication error. It does not make clear the extent to which that error or alarm fatigue contributed to the patient’s death.
