Alarm fatigue has resulted in the death of a 60-year-old patient at the UMass Medical Center, the second reported death attributed to this phenomenon in four years at the facility. Alarm fatigue is also known as the “cry wolf” syndrome, according to ABC News, and it describes the tendency for medical staff to ignore the constant stream of beeps and warning signals that plague hospital (and sometimes nursing home and assisted living, to a lesser degree) hallways and corridors.
Implementing additional alarms may seem to be the solution. A louder, shrill beep to signal a dire emergency appeals to logic, yet more alarms simply add to the cacophony already invading the halls. More alarms simply makes it even more difficult to discern those that are important from those serving as a reminder that it’s time to perform a standard, non-urgent task.
Standard alarms become so mundane that nurses and other professionals staffing hospitals and nursing homes tend to drown out the noise in order to focus on the task in front of them. But this tendency to drown out the constant beeps becomes dangerous when important alarms go unnoticed and unattended to.
Not having alarms to signal less important events isn’t the answer, either. Device manufacturers must incorporate appropriate notification signals or find themselves liable should a simple need be overlooked as a result. In the healthcare setting, even the simplest oversight can lead to disaster.
Alarm fatigue and “too much information” (TMI) a growing healthcare concern
According to the FDA’s Manufacturer and User Facility Device Experience database, approximately 566 deaths in the United States have been attributed to alarm issues between 2005 and 2008. An overhaul of the system would require cooperation from health systems, physicians and medical device manufacturers. The solution may lie in a systematic fine-tuning of current alarms, investigating areas in which the threshold can be raised; for example, raising the point at which a blood oxygen level signals an alarm to increase the importance of an individual alert.
The Association of Advancement of Medical Instrumentation is hosting a conference next month in Herdon, Va. More than 250 medical device manufacturers and other healthcare professionals will convene for a medical device alarms summit with alarm fatigue as the central focus of discussion.
Medical errors in any sense are devastating for both families and the professionals involved. But a collaborative effort to improve the effectiveness of medical alarms could result in a reduction of deaths and errors resulting from alarm fatigue.
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