Alarm Fatigue Revisted

Originally posted 2-21-2011:
Back in August, I wrote about the problem of Alarm Fatigue in healthcare. Alarm Fatigue occurs when care givers hear medical device alarms so often, they develop a "cry wolf" reaction and start to unknowingly ignore those alarms.  The Boston Globe recently published an interesting special report about the issue. 

The article discusses a couple of specific cases in which alarms were ignored before a patient death. The article also highlights a number of studies showing how often alarms are ignored or just completely missed by hospital staff.  This is a specific item from the article I want to highlight:

"“We are at the point where we all know [alarm fatigue] is a problem,’’ [Dr. Brian Lewis, a cardiologist and medical officer in the FDA’s division of cardiovascular devices] said. “We know we’d like these devices to serve the public health better. But we need specific direction from providers on how these devices should be changed.’’

From reading this, I think this is a real opportunity for both hospitals and device manufacturers to work closely together to solve a real patient safety issue. Device manufacturers will tend to design alarms to be overly sensitive because “Missing a real event is much more costly to the manufacturer.’’  I think the algorithms and designs behind these alarms should be looked at a little closer to see if they can find a safe balance to keep alarms from being over sensitive. I said in my previous post that "device manufacturers should continue to study and understand user tasks and workflows to help evaluate which alarms are necessary." This is the basis of User Centered Design, which is a key philosophy that I believe helps lead to safer healthcare technology products. In this case, I think it will help avoid those situations where the alarm silence button on a device is blindly pushed or alarms get missed in the rest of the noise.  It will not solve the problem completely, but it would be a big step toward helping the alarm fatigue issue.