The UMass Memorial Medical Center has recently increased its efforts to identify and combat negligent nursing care, which has resulted in the preventable patient deaths at the hospital. The initiative came after the Massachusetts hospital became aware of the problem called “alarm fatigue,” where nurses are unconsciously tuning out patient monitor warning alarms after persistent exposure to their sights and sounds. In Massachusetts, at least two patient deaths at UMass Memorial Hospital and one at Massachusetts General Hospital have been attributed to alarm fatigue and inadequate nursing response to patient crises. Alarm fatigue has also been linked to serious personal injuries and medical errors.
Earlier this fall, the second patient death in four years involving alarm fatigue occurred at Umass Hospital. In that case, a 60-year-old Massachusetts man died in the intensive care unit after alarms signaling heart and respiratory distress were disregarded for nearly an hour. Massachusetts state investigators found that the death occurred in August 2010, but was not reported to the Department of Public Health until the following spring. Investigators cited various violations by the UMass Memorial Medical Center, including not responding to patient warning alarms “in a timely manner.” Four years ago, similar nursing negligence was blamed for another preventable death, when nurses at the hospital ignored alarms that warned of an elderly Massachusetts man’s cardiac maladies. In the ensuing Massachusetts Department of Health report, it was found that the decedent’s monitors were sounding alarms for over an hour, warning that his heart rate and breathing had sped up and his blood oxygen level had fallen. This was followed by a higher pitched “critical alarm,” which warned that the patient had stopped breathing. Investigators noted in the report that “there was no evidence that nursing had responded to the alarms during this period of time.”
According to the Boston Globe, “alarm fatigue” is not a problem limited to nurses and hospitals in Massachusetts. In fact, a recent study shows that nationwide this type of medical malpractice has led to at least 200 patient deaths since 2005, and likely hundreds more that were not correctly reported. Maria Cvach, an assistant director of nursing at Johns Hopkins Hospital in Baltimore and specialist on medical alarm fatigue told the Globe that, “I don’t think any hospital has fully solved this problem.” The UMass Medical Center is now taking steps to eradicate the issue, informing the Massachusetts Department of Public Health that it is actively taking steps to improve patient care. These include monthly drills in the intensive care unit, where nurses are timed in responding to patient alarms. The hospital has also held seminars on preventing this type of alarm fatigue in Massachusetts and on the national stage. One proposal is for advanced monitoring devices, which more accurately gauge the seriousness of a patient’s condition before sounding alarms. Theresa Gallivan, associate chief nurse at Massachusetts General Hospital, told the Globe that she is a proponent for more advanced monitoring devices, which will reduce the number of false alarms and allow nurses to respond more efficiently to actual crises. According to Gallivan, though, “there is a mismatch of technology and what we are trying to achieve.”