Anyone who has had the experience of visiting an Emergency Room has no doubt heard the nearly incessant cacophony of beeping sounds originating from a multitude of monitoring equipment. 

You would also have noticed that in the majority of cases these monitoring devices keep on beeping while the nursing staff, obviously oblivious to the symphony of sound, keeps on working on their seemingly endless paper work.

ALARM FATIGUE
My original intent to write a brief piece on the risk associated with what is generally known as alarm fatigue, had been motivated by an article I had read on Google news on April 8, 2013 entitled: “Joint Commission warns about dangers from alarm fatigue.”

Having read the article that confirmed what I had observed while visiting family members who had been admitted in emergency rooms, I initially thought of some suggestions that could easily be implemented to reduce the number of false alarms and suggest some simple solutions to monitor vital signs via control charts. But something else caught my attention.

The fact that a series of articles on alarm fatigue had been written in 2013 seemed odd to me because I had noticed the problem a few years earlier.  However, further searches revealed that a major Evidence Report had been written as early as 2001.[i]  To summarize this 600 plus page report would require thousands of words and the interested readers would be best served by reading the report or the appropriate sections (of which there are many) for themselves.

REDUCING RISKS
My emphasis had now shifted: what improvements were made in reducing risk associated with alarm fatigue in the last twelve years?  Based on my experience, none of the suggestions proposed in 2001 had been implemented, at least not in the two hospitals I had visited on numerous occasions over the past two and half years. And so, patients on ventilators, blood pressure monitors, infusion pumps, and other monitoring equipment are apparently still at risk today of having their beeping equipment ignored by the nursing staff.  Given that a study revealed that monitoring equipment in intensive care unit beeps on average every 37 minutes, it is not surprising but alarming to learn that in 72 percent of the cases no action was taken.[ii]

THE QUALITY SOLUTION: CONTROL CHARTS
After reading a dozen or so articles on the subject of alarm fatigue I was surprised to learn that none of them made reference to the use of control charts–techniques that have been used in the manufacturing world for well over 80 years.  Control charts could be used to identify out-of-control points or special causes which would generate a different alarm frequency.  Naturally this simple idea would need to be reviewed and tested by medical experts.  To my surprise, when I proposed the control chart suggestion to a medical consultant his immediate answer was:  it will never be adopted because this would provide a record of the monitoring device and whether or not someone took action—too much legal risk.  This perhaps explains why twelve years after the Evidence Report was published the subject of alarm fatigue is still being written about!

Legal risk seems to have, for the moment, outweighed patient risk.