Have any of you seen or experiences alarm fatigue? I found this article interesting especially these days when the number of alarms just seems to be growing. I myself have witnessed (working on a busy medical floor) where alarms were going off, and if a nurse was not around nobody was checking on the patient.
'Alarm fatigue' linked to patient's death
US agency says monitors at MGH unheeded
By Liz Kowalczyk
Globe Staff / April 3, 2010
Federal investigators concluded that "alarm fatigue'' experienced by nurses working among constantly beeping monitors contributed to the death of a heart patient at Massachusetts General Hospital in January.
In a report released yesterday, the investigators said10 nurses on duty that morning could not recall hearing the beeps at the central nurses' station or seeing scrolling tickertape messages on three hallway signs that would have warned them as the patient's heart rate fell and finally stopped over a 20-minute span.
Additionally, federal investigators said the volume for a separate audible crisis alarm on the patient's bedside monitor was turned off the night before by an unknown person. Mass. General executives had previously told the Globe that this crisis alarm had been inadvertently turned off.
But investigators for the Centers for Medicare & Medicaid Services said that desensitization to alarms that actually sounded also was a factor in the patient's death.
Mass. General executives said yesterday thatthey have taken numerous steps to correct the problems, including disabling the off switches for alarms on bedside cardiac monitors and that the federal Medicare program approved the hospital's plan for addressing the issues.
Federal inspectors reviewed the case as part of a random routine inspection at the hospital from Feb. 2 to Feb. 16. They found additional problems during the visit as well, including locating video screens where visitors could see patients who were being monitored in their rooms.
Patient safety officials across the country have said the heart patient's death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.