Silencing Hospital Alarms

There's a great story on NPR today about a Boston hospital's success in reducing random alarm noise. In major part by giving nurses authority to adjust devices alarm settings based on what they knew of patients' conditions, a single hospital unit was able to reduce alarm noise from 90,000 beeps per week to only 10,000.

Why is that good? First, the incessant beeping of monitoring and other devices is very annoying to patients and staff alike. Second, too much beeping--about 350 beeps per patient-bed per day!--can induce alarm fatigue, causing staff to miss the really important signals when they occur. The Boston Globe attributed about 200 deaths over 5 years to alarm fatigue; the Joint Commission has reported 98 alarm-related sentinel events in a 3.5 year timespan, resulting in 80 deaths and over a dozen instances of permanent disability. The Joint Commission has therefore recently published new standards relating to alarm safety. It turns out that a lot of that beeping is really unnecessary; the Joint Commission has cited industry estimates that between 85 and 99 percent of hospital alarms aren't clinically actionable.

A paper on the Boston's hospital's alarm experience is here. A special alarm-safety issue of Horizons magazine (published by the Association for the Advancement of Medical Instrumentation) is here.

86% of Medical Error Goes Unreported

Hospital incident reporting systems were informed of only 14% of errors that harmed Medicare patients, according to this report on a recent survey undertaken by the Department of Health and Human Services Office of Inspector General. Hospital staff didn't perceive 61% of adverse events as reportable. Another 25% were classified as of a type commonly reported, but somehow not reported this time.

Remember what the Institute of Medicine told us, back in 1999, about how we ought to be dealing with medical errors? We're supposed to report them all, in a blame-free atmosphere, in order to gather information that will help us change the systems which give rise to them. The idea was that we'd make more progress by reporting error in this blame-neutral way than by either a) covering the error up or b) blaming error on particular human beings. The basic assumption was that most medical error resulted from flawed systems (training systems, oversight systems, information systems, and so on) which put hospital staff at predictable and preventable risk of making mistakes.

Some progress has been made. But this latest report shows how very far we have to go. A 14% reporting rate is absolutely dreadful, particularly because this is the report-rate for events that actually harmed Medicare patients. The IOM's goal was that not only harmful errors, but also "near-misses"--events that could have harmed patients, but luckily didn't--should be reported.

The Inspector General recommends that the government establish a list of reportable events, so that there's clarity about what needs to be reported and what doesn't; and that CMS (the Medicare agency) cooperate with accrediting bodies like the Joint Commission to establish review of hospital reporting procedures. Accrediting bodies currently tend to concentrate on what's done with reported information, rather than on the accuracy and breadth of the reporting process itself. That clearly needs to change.