Deadly Alarms

Monday, February 14, 2011

The problems caused by warning fatigue and false alarms have intersected to kill hospital patients, as a story from the Boston Globe reports.

[Madeline] Warner died after nurses failed to respond to an alarm that sounded for about 75 minutes, signaling that her heart monitor's battery needed to be replaced, state investigators found.


Hospitals, monitor manufacturers, researchers, and federal regulators are similarly grappling with how to reduce the rash of unheard and ignored alarms and other patient monitor problems -- which the Globe reported yesterday was linked to more than 200 deaths nationwide between 2005 and mid-2010, and, experts say, probably far, far more. But they are finding answers elusive. [link added]
It is sad to see anyone die like this, but the involvement of regulators in "solving" this problem immediately causes me to wonder what role rights-violating prescriptive laws might have played in causing these two hundred plus deaths.

For one thing, it is clear that such alarms are being over-used:
Klugman decided to conduct a study of patients on cardiac monitors at UMass Memorial and three other Massachusetts hospitals over the course of one week in 2008. He found that at UMass alone, 40 percent of patients, or 73, didn't need to be on monitors at all, based on American College of Cardiology criteria.

"Cardiac telemetry saves lives, there is no question about that," Klugman said. "But there's the potential of unintended consequences and that's what's happening here. It's overused."
One wonders whether government regulations or defensive medical practices caused by a tort system in dire need of reform might account for over-use of (just) this type of alarm (by nearly 70 percent at this hospital). Also, might the costs of these (and many other similar) regulations and the related problem of defensive medicine help account for the nursing shortage?

These questions never arise in the article, but based on a Thomas Sowell column on another safety-related topic, perhaps they should have:
Since there were thousands of airline flights cancelled in the name of safety, this means that there were at least tens of thousands of passengers unable to take the flights they had booked.

Some of those passengers drove cars to reach the destinations to which they had originally planned to fly. Since automobile fatality rates per mile have long been several times as high as airline fatality rates per mile, this means that the dangers to life and limb have not been reduced by this political grandstanding.

Instead people have been exposed to greater dangers -- in the name of safety!
Along similar lines, it is a fair question to ask whether hospitals would be faced with "alarm fatigue" at all if doctors felt freer to use their own judgment about whether a patient actually needed a monitor or an alarm of some kind.

Ominously, all the solutions under consideration involve more expense, more regulation, or both. At no point is the "need" for even more of what might have led to these deaths questioned.

-- CAV

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