MGH Patient Death Raises Concerns about Patient Monitoring Device Alarm Effectiveness

A male patient at Massachusetts General Hospital died last January after the crisis alarm on his heart monitor was accidentally switched off and left off. The patient was not discovered to be in crisis until a nurse came by during a routine check. The hospital has not said how long the man had been in crisis before the nurse came by.

The patient’s death highlights a growing problem for hospitals nationwide. Failure by staff to acknowledge and respond to alarms is one of the most frequent and serious problems facing hospitals today. The ECRI Institute, an independent nonprofit organization that researches ways to improve patient care, recently released its list of “Top Ten Health Technology Hazards” for 2010. “Alarm Hazards” ranked in at No. 2, passing other high-ranking health risks such as “High Radiation Dose from Computed Tomography” and “Retained Devices and Un-retrieved Fragments Left in Patients.”

A Nationwide Problem

Across the nation, hospitals are taking extra time to examine the effectiveness of alarms on patient monitoring devices. Every year, deaths are reported because alarms either malfunction or are turned off, unheard, or ignored. Kathryn Pelczarski, director of ECRI’s applied solutions group, says that there were 237 alarm-related deaths between 2002 and 2004, and alarms made up 12 percent of the 2,200 medical device problems reported to ECRI between 2000 and 2006.

“Alarm Fatigue” a leading Cause of the Problem

As hospital technology has expanded both in terms of application and complexity, the number and types of alarms have also expanded. As a result, nurses and other caregivers often find themselves overwhelmed to the point that alarms lose their urgency. Pelczarski, calls this problem “alarm fatigue.” When alarm fatigue occurs, nurses begin ignoring and even turning off alarms. Additionally, since nurses are busy responding to a vast array of alarms, it can become difficult for them to hear and recognize each individual alarm.

New Remote Patient Monitoring Technology as a Solution

Today, new technologies and tools are emerging to help hospitals overcome this obstacle in providing quality patient care.

Dalcon Alert is one such tool that provides caregivers with an efficient way to acknowledge and respond to multiple alarms. Dalcon Alert is a Remote Patient Monitoring system that simultaneously connects with various patient monitoring devices such as heart monitors, IV pumps, ventilators, pulse oximeters, and more. When a patient monitoring device triggers an alarm connected to Dalcon Alert, the system sends a text message to wireless phones (or pagers) held by hospital staff.

The system is highly customizable.  For example, less critical alarms can be sent only to the nurses who are responsible for the patient whose device generated the alarm.  Highly critical alarms, such as heart monitor alarms, can be sent to the entire nursing staff to assure that such alarms do not go unnoticed.

Dalcon Alert also routes alarms to a PC display at the nursing station running the system’s Alert Management software, allowing nurses to manage all active alarms. Alarms cannot be removed from the Alert Management queue until dealt with at the point of care.  As a result, accidental staff negligence is eliminated.