In the investigation that ensued, the Centers for Medicare and Medicaid Services reported: “Nurses not recalling hearing low heart rate alarms were indicative of alarm fatigue which contributed to the patient’s death”. Despite multiple low heart rate alarms that occurred prior to the patient’s cardiac arrest, no-one working on the unit that day recalled hearing the alarms. In 2010, excessive alarm burden was exposed by the press as a patient safety concern by the highly-publicized death of a patient who was being monitored at a prestigious medical center. ![]() ![]() The end result is that clinicians are exposed to a high number of physiologic monitor alarms over the span of their 8–12 hour shift causing excessive alarm burden. All too often, these incessant alarms are triggered by something as benign as motion artifact from activities such as brushing one’s teeth. Critical arrhythmia alarms such as asystole or ventricular fibrillation are configured as “latching” alarms that produce incessant sounds that do not cease until a clinician silences the alarm. In addition to the plethora of parameter alarms, physiologic monitor devices also contain arrhythmia computer algorithms that trigger an alarm when a change in cardiac rhythm is detected. The nurse pictured here gave written informed consent to publish this photograph supplied by the San Francisco Chronicle newspaper (with permission) for their story on alarm fatigue at. ![]() Physiologic monitor device in Intensive Care Unit.īedside patient monitor (GE Healthcare, Milwaukee, WI) displays multiple physiologic waveforms and vital sign measurements.
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