Two patients die in Los Angeles after ICU alarms fail

Nurses Activism

Published

Specializes in Vents, Telemetry, Home Care, Home infusion.

Faulty monitoring system cited in deaths at King/Drew. Medical firm defends the device.

By Charles Ornstein and Tracy Weber

Times Staff Writers

August 22, 2003

http://www.latimes.com/news/local/state/la-me-kingdrew22aug22,1,7817379.story?coll=la-news-state

Two patients at Martin Luther King Jr./Drew Medical Center have died since June 30 after audio alarms on machines monitoring their vital signs failed to alert nurses that they needed emergency attention.

The emergencies for the patients, both women, were discovered too late for them to be revived.

The first patient, 33, died June 30, just one week after the public hospital installed the new monitoring system, the device's manufacturer and Los Angeles County officials confirmed Thursday. Two weeks later, on July 15, a 52-year-old died.

State health officials confirmed that they were investigating the deaths after being notified by the hospital.

After the second death, Welch Allyn Inc., the manufacturer, found physical damage to the nearly new central monitoring unit that could have caused its speakers to malfunction, company officials said Thursday. The company determined that the first patient who died had been tracked by the wrong monitor, which might have confused nurses.

The damaged unit was replaced and the monitoring system is still in use at the hospital. The nurses were retrained and no problems have been reported since, Welch Allyn officials said.

The system can track the blood pressures, heart rates, oxygen levels and temperatures of 60 patients from a single computer at a nurses' station. The computer receives information from wireless bedside monitors in the patients' rooms and provides audio and visual alarms when problems occur.

Dr. Alfred Forrest, the hospital's acting medical director, did not return calls for comment.

John Wallace, a spokesman for the Los Angeles County Department of Health Services, said his agency also was looking into the deaths at the county-run facility. He declined to release the patients' names or to say what King/Drew personnel believe went wrong.

"Right now there's an investigation that is ongoing, and to start making conclusions before everyone has all the facts would really not be in the best interests of fundamentally fixing this issue," Wallace said. "We want to correct it so it doesn't ever happen again."

Wallace said King/Drew was continuing to use the monitors because they had been approved by the Food and Drug Administration and "are actually superior devices to what we had" previously. But he said the county had insisted upon the additional training and replacement equipment.

Welch Allyn reported the deaths to the FDA, which tracks the performance of medical devices, as required. Even so, the company said it was not sure that any malfunction had contributed to the deaths.

"At this point, we really don't have any conclusions and can't make a statement about whether the potential failure of an alarm would have contributed to the cause of either incident," said Tom McCall, corporate director of communications for Welch Allyn.

Other signals, such as visual alerts on the monitor screens and bedside audio alarms, were working and ought to have signaled a problem, he said.

"You've got multiple redundancies built into the system to try to enhance patient safety," McCall said.

Wallace said the county health department was trying to determine how long the patients had been in distress or deceased before the problems were discovered by doctors or nurses making routine rounds. The first woman was dead when medical personnel reached her. Doctors unsuccessfully attempted to resuscitate the second woman.

McCall said Welch Allyn has installed more than 1,000 monitoring systems in hospitals worldwide and "we have not had an incident like this reported."

According to the FDA database that tracks problems with medical devices, there have been 10 other reports of problems with Welch Allyn's central monitoring system since 2001. It was unclear Thursday how that compared with the record of other devices or manufacturers.

In three instances, the Welch Allyn system locked up and had to be manually restarted. The system briefly stopped working in two other cases, forcing medical personnel to resuscitate one patient. Other reports dealt with mix-ups in patient information displayed on the central monitors. It did not appear that any of the patients involved in those incidents had died.

FDA officials said they take death reports very seriously and that each is followed up.

"What we're looking for is any specific performance problem with the device that might indicate that the problems are broader than the case at hand," said Steve Sykes, deputy director of the FDA office that reviews reports of problems associated with medical devices.

"If it is, in fact, some sort of actual mechanical function problem with the device, then the device can be recalled," Sykes said. "We can insist on that, but companies generally do that themselves."

The group that accredits hospitals said it hadn't been informed of the monitor problems at King/Drew, but such reports are voluntary. The group, the Joint Commission on Accreditation of Healthcare Organizations, requires that hospitals examine the causes of any unexpected death and devise ways to reduce the risk.

Even so, the commission now requires hospitals to regularly test clinical alarm systems to ensure that they are loud enough to alert nurses and doctors.

Commission officials said the topic first arose when the group did a study of patient deaths related to use of mechanical ventilators and found that alarms at times malfunctioned, were not turned on or were not heard.

"If something goes wrong and it's not recognized, things happen fast and somebody gets hurt," said Dr. Richard Croteau, the commission's executive director of strategic initiatives. He called alarms a "critical component" of the health-care system.

King/Drew, based in Willowbrook, was created in response to the Watts riots in 1965. Over the years, it has faced numerous complaints about the quality of its medical care and physician-training programs.

Recently, several training programs have been warned that, unless they improved, they would lose their accreditation by the body that oversees graduate medical education. In addition, budget woes have forced the hospital to lay off dozens of doctors this summer.

https://allnurses.com/forums/showthread.php?s=&threadid=42661

It seems to me that unless there is a competent person observing the monitor at all times the very use of such equipment is questionable.

What do YOU think?

I am just too lazy to retype. Karens posting is more colorful & attractive too!

Specializes in Nurse Anesthetist.

King hospital has lost their JCAHO cert! They are in deep poo!

It is a sad commentary on nursing that administration feels that if your alarms are set properly then the patient is safe. When I questioned the staffing in ICU--when I felt the patients were too sick for an RN to have two, that is exactly what I was told. I no longer work in an ICU, I felt the situation was no longer safe. This after many years of experience. The alarm system is no subsitute for adequate staffing nor is it a set of eyes to watch the patients. This is an example of why you cannot trust your alarm to keep your patients safe. Computer systems can and do fail. Nursing must learn to speak up, or vote with their feet if they are not being heard. Somehow these dangerous practices must be stopped. Linda

And is it safe to predict that the blame will fall on the nurses?

Specializes in NICU, PICU, PCVICU and peds oncology.

A couple of weeks ago one of our peds patients nearly died. He was almost ready for transfer to the intermediate care floor but still being monitored (Spacelabs ICU model, but pretty elderly) for heart rate, resp rate and sats. His nurse had turned away to draw up a med, turned back to give it and discovered the baby severely bradycardic, with a heart rate of 44 and falling, sats in the 50s and apneic. No alarm, no visual message that there was a problem, nothing. The alarms only started going off after she had started compressions. The heart rate went as low as 21, and his sats weren't picking up. BP dropped to 23/11 and he was tubed without drugs. If this event would have happened half an hour earlier, when his nurse was on break and the nurse at the next bed was covering, this kid would be dead.

With the number of nuisance alarms this particular line of monitors delivers, we were all shocked that there was none that night.

Specializes in ER.

I think some moniters have a 20 sec delay, esp for apnea, so if you consider the gasping breaths the patient can be very dead by the time the alarm goes off.

Specializes in Hospice, Critical Care.

All comes down to staffing. Sure someone should have noticed "visual" alarms...if they weren't in another patient's room knee-deep in God-knows-what. And the charge nurse probably ahs a patient assignment. Or the monitor tech wasn't even looking at the monitors (60?!) since nothing was alarming.

Our unit's ratio has been running 3:1 (they say because it's low census right now). And soon our dedicated charge nurses will no longer be dedicated to charge...we will be taking assignments. So that leaves WHO at the monitors? No one.

Specializes in Pediatrics, Geriatrics, Call Center RN.

ICU is not at all my specialty. But is it unrealistic to have had both monitoring systems on the patient at one time until the new machinerywas checked out. Any if the new technology is so much better why did it allow 2 people to die, and the old stuff didn't. I think I read in the article a statement "We have never had an incident such as this." Is the old stuff that bad then????

+ Add a Comment