Since 2013, healthcare accrediting agency The Joint Commission has had a National Patient Safety Goal addressing clinical alarm systems. In 2020, problems with responding to clinical alarms was number 8 on the top 10 list of sentinel (never) events reported to The Joint Commission by accredited or certified hospitals or facilities.
Physiologic monitoring systems are used to automatically measure vitals including blood pressure, heart rate, respiration rate, oxygen saturation, ventilation/ventilator settings, and electronic fetal monitoring, just to name a few. The systems have audible and visible alarms to notify nurses and physicians when the values are too high or too low, or there is an equipment problem.
A Pennsylvania patient safety study found that nearly all deaths where physiologic monitoring was an issue were caused by human error, rather than equipment failure. That’s certainly consistent with my experience as a Texas medical malpractice attorney.
There are several reasons that botched response to clinical alarms continues to be a problem that menaces patient safety.
• Alarm fatigue. Some units are noisy. Multiple patients with multiple physiologic monitors chirping and giving feedback. In some critical care units, it’s typical to have around 12 clinical alarms per patient each day. This makes it difficult for the nursing staff—that’s often short staffed—to differentiate between emergency alarms and more routine notifications.
When this happens, doctors, surgeons, nurses, and other providers can violate the standard of care by turning off the monitor volume or turning off the equipment altogether.
One anesthesiology expert told me about a case that she had reviewed where the surgeon convinced a certified registered nurse anesthetist (CRNA) to turn off the anesthesia machine’s audio feedback. After a while, the surgeon recognize that the patient’s body was cold. When he asked the CRNA about it, they suddenly realize that the patient had been dead for a while.
While that’s an extreme example, it’s not at all uncommon to learn about a nursing station ignoring alarms or patient call buttons. When those notifications are connected to an emergency situation, the failure to follow up on monitoring can mean the difference between life and death.
• Poor training, policies, and procedures. When no one is clearly responsible for responding to alarms and notifications from clinical equipment, it’s often no one who responds. Hospital leaders should have clear policies and procedures identifying responsible staff members in providing appropriate training on how to use equipment, including when new physiologic monitoring is introduced to units or operating rooms.
• Transition points in care. In aviation, experts understand that the most dangerous times of a flight are taking off and landing. In health care, transitions between care can be equally risky and dangerous times when clinical alarms aren’t appropriately monitored or there is a communication breakdown. That can be between nurses and transfer personnel taking a patient to a procedure room or to the radiology department for imaging. One of the fairly recent developments that I appreciate in hospitals is the handoff communication. It’s essentially a timeout when one doctor or provider pauses to brief the next physician or provider about key elements of the patient’s care. A good handoff communication can avoid things falling through the cracks, including clinical lots.
If you’ve been seriously injured because of poorly managed hospital clinical alarms in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for free consultation about your potential case.