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When Medical Alarms Call Wolf, Patient Safety Is At Risk.

Posted Monday, July 18, 2016 by Tom Degan

In Aesop’s fable, “The Boy Who Cried Wolf,” a young shepherd finds it amusing to make his villagers think that a wolf is attacking his flock. When the villagers come to his rescue, they learn it is a false alarm. Later, when a wolf attacks his flock his alarm is ignored and the wolf kills the shepherd and his flock. This fable is the genesis of the often-used saying “never cry wolf,” which has applications to modern healthcare.

Currently it is not unusual for doctors, nurses, and other healthcare providers to be bombarded with hundreds of alarms throughout their workday. Indeed, anyone who has walked through a modern hospital has heard alarms blaring from patient rooms. Many of these alarms are not related to medical emergencies.

According to research studies, on average there are about 480,000 patients in hospitals, and each patient generates approximately 135 clinical alarms per day. Studies show that more than 90% of these alarms result in no action. That means across the U.S. healthcare providers experience 8 million false alarms each day. When healthcare practitioners constantly receive false alarms, they become desensitized just like the villagers in Aesop’s fable.

When alarms are constant and mostly unnecessary, nurses and other healthcare practitioners tend to turn the alarms off, the volume down, or increase the amount of time the alarm can sound. Ignoring or delaying alarm systems can endanger patients’ lives and increases the potential for medical malpractice.

The Emergency Care Research Institute has repeatedly listed hospital alarms among the top five greatest medical technology hazards. In 2015, hospital alarms ranked number two. As a result, since 2014 hospitals within the U.S. are required to develop and review their alarm management policies on a regular basis.

Dr. Ilene Busch-Vishniac, an acoustical consultant from Johns Hopkins University, has been studying this issue for more than a decade. This spring she presented her findings to the Acoustical Society of America’s Meeting in Salt Lake City in May. According to Dr. Busch-Vishniac false alarms “lead to roughly 200 deaths and 300 episodes, which includes loss of function or permanent damage to the patient.”

Dr. Busch-Vishniac outlined an “alarms of the future” research program she intends to pursue. “The first task is to compare the medical outcomes of patients when alarms sound within their area vs. when alarms are intentionally muted and sent to staff via pagers or cell phones,” she said. “This will help to establish whether alarms potentially harm patients, as well as save lives. We’ll also explore when alarms should sound, which sounds should be used, and ways to make alarm systems more intelligent by combining information from multiple medical devices.”

Dr. Busch-Vishniac’s goal is to design optimum alarm systems for hospitals that can be integrated into hospital equipment within 20 years. The abstract for her presentation can be found here:

Death by alarm: An error model of hospital alarms

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