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Arizona Medical Malpractice Blog

Human Error Primary Factor in Ventilator Alarm-Related Patient Deaths

Wednesday, December 28, 2011

An increasing number of patient deaths associated with ventilator alarm-related errors confirms to Arizona medical malpractice lawyers that alarm fatigue is a much-neglected aspect of patient safety in the United States. According to the Boston Globe, more than 100 people have died over the past 6 years alone as a result of ventilator alarm-related errors.

What is even more concerning is that few of these alarm-related errors are due to defective ventilators or ventilator malfunctioning. Human error seems to be a primary factor in these errors and deaths.

An investigation by the Boston Globe and the ECRI Institute found that a total of 119 people died in ventilator alarm-related incidents between 2005 and 2011. Defective or malfunctioning ventilators were associated with only 2 of those fatalities. The rest were all the result of human error on the part of caregivers or healthcare staff. In these cases, caregivers or nurses either ignored the ventilator alarms, or did not hear them. In other cases, the alarms were set incorrectly.

Alarm fatigue and its role in propagating medical errors is something that Arizona medical malpractice attorneys have been probing deeper into. The vast number of ventilator and cardiac monitor alarms in hospitals and home healthcare settings leads to nurses and caregivers becoming so overwhelmed by the alarms that they may ignore these when they do go off. Many times, alarms are false, and as a result, caregivers become used to false alarms, and may not respond as quickly or at all, when there is an alert.

In 2010, the Food and Drug Administration reported that there had been reports of 800 alarm-related adverse outcomes last year alone. Most of these were classified as ‘preventable,’ and were associated with human error. In September this year, the agency issued an alert that too many alarms were being neglected or ignored, and also warned that caregivers and nurses were becoming much too dependent on alarms. In fact, the ECRI Institute has now ranked alarm hazards as one of the top 10 health technology hazards.

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