The Problem with False Alarms

According to the Boston Globe, CMS has found that “alarm fatigue” contributed to a patient death at Massachusetts General Hospital in January. Although the patient’s plummeting heart rate reportedly triggered an alarm at the nurses’ station, it was apparently ignored. A second alarm did not sound because it was turned off.

The problem of excessive false-positive alarms was described in 1997 by CL Tsien and JC Fackler. They observed a single bed in an ICU in a university hospital for 10 weeks. After 298 hours of monitoring, they determined that 86 percent of 2,942 alarms were false-positives and that an additional 6 percent were clinically irrelevant true alarms. Just 8 percent of all alarms were clinically significant.

Researchers in alarm fatigue appear to believe that more in “intelligent” alarms can reduce the overload, and generally call for more research on the problem.

Comments (4)

Trackback URL | Comments RSS Feed

  1. Virginia says:

    Bruce Schneier talks about the same problem as it relates to the TSA. They have so many tubes of toothpaste that set off alarms that the employees stop paying attention to what they are scanning.

  2. Devon Herrick says:

    When 90% of alarms are false-positives, the people responsible for monitoring the alarms will only put forth one-tenth the attention to any given alarm.

  3. Joe S. says:

    I have had this problem myself. If the alarm were real I would be dead.

  4. Vicki says:

    i assume that what Joe means is that the peple at the nurses’ station tend to ignore all the alarms, assuming that they are all false. So when the one true one occasionally comes along, its good bye patient.