As we all know, hospitals can be a loud place. Medical device alarms seem to be going off constantly. Whether from hospital beds, medication pumps, and other medical devices, hospital staff can become so desensitized to these sounds that they no longer hear alarms or begin to ignore them. This is commonly referred to as "alarm fatigue." According to investigations conducted by the Boston Globe in 2011, hundreds of patients may die every year from alarm fatigue. The Food & Drug Administration is also aware of the problem. Just recently, the FDA announced new measures to reduce alarm fatigue including more intense pre-market reviews of medical devices equipped with alarms. As a medical malpractice lawyer that has prosecuted an alarm fatigue case that resulted in a patient's death, I know alarm fatigue can have deadly consequences. Although the FDA's new efforts should reduce the risk of alarm fatigue, I believe hospital and nursing staff must also do more.
About ten years ago, I represented the family of an Alzheimer's patient who, while wearing an electronic ankle bracelet, triggered a stairway alarm at an Illinois nursing home. The alarm had gone off numerous times that day. After my clients' father triggered the alarm that lead to the third floor stairway, no one conducted a head count or initiated any other safety protocols such as locking down all exits. Instead, the alarm was simply re-set and the staff went back to what they had been doing. In the meantime, my clients' father proceeded to down to the first floor, walked through the lobby and out the front door of the nursing home without anyone noticing. Once the nursing home staff later realized he was missing, it was too late. Despite an intensive search by local authorities, family and friends, my clients' father remained missing for nearly a week before he was found dead a in a wooded area one mile from the nursing home. He had died from exposure.
After taking the first deposition in this case, it was obvious what had happened. The staff was so used to hearing the alarming going off, they became desensitized. When my clients' mentally ill father set off a legitimate alarm, the nursing home staff effectively ignored the alarm when they just re-set the alarm rather than follow their own safety protocols. Had this been done, my clients' father would have never made it from the third floor to the lobby and out the front door.
In order to reduce the potential deadly consequences of alarm fatigue, the FDA is now intensifying its pre-market review of medical devices that sound alarms. The objective is to reduce the number of unnecessary alarms in hospitals and nursing homes. The FDA will also be providing additional training to its medical device reviewers on alarm standards and safety. Although medical device improvements are an important step toward reducing alarm fatigue, more must be done. Hospital staff and nursing home staff must also do a better job at responding to alarms. In addition to reinforcing the importance of following alarm protocols, hospital and nursing home staff must also be properly trained on how to avoid recognize and avoid alarm fatigue. Without improvements in both technology and training, we will only continue to see unnecessary patients deaths and medical malpractice lawsuits from alarm fatigue.
Boston Globe, FDA Working To Trim Hospital 'Alarm Fatigue', March 24, 2012.
Boston Globe, "Alarm Fatigue" A 2d Factor In Death, September 21, 2011.