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State reports detail 11 patient deaths linked to alarm fatigue in Massachusetts

The elderly man had fainted and suffered a seizure. Doctors in the MetroWest Medical Center emergency room were worried his symptoms might foreshadow a heart attack. So he was admitted to the hospital and placed on cardiac monitoring.

The next morning, doctors’ suspicions proved true. A nurse found the patient without a pulse, slumped in a chair.

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The monitor’s crisis alarm should have sounded when his heart stopped. It didn’t, however, because the machine’s cables had slipped off the man’s chest nearly three hours earlier. That triggered a different, “leads-off’’ alarm, but someone silenced it without fixing the problem, and subsequent beeps were either not heard or ignored, according to a state Department of Public Health investigation.

Similar scenarios have occurred repeatedly in hospitals across Massachusetts. Nurses can become desensitized to the constant blaring of monitor warnings, many of them false alarms - a phenomenon called alarm fatigue.

Through public records requests, the Globe found at least 11 deaths in Massachusetts since 2005 linked specifically to lack of response, or inadequate response, to alarms on cardiac monitors in hospitals. At least three involved leads-off alarms - a lead is the sticky patch at the end of a monitor cable that adheres to a patient’s skin. Three involved alarms for a low battery or other malfunction that went unnoticed or were ignored.

Since the Globe reported on alarm fatigue deaths earlier this year, the newspaper has obtained records detailing more of these cases in Massachusetts. Here is a description, based on documents obtained from the state health department, of the 10 cases in addition to the one at MetroWest in 2006:

January 2007 - Madeline Warner, 77, died of cardiac arrest at UMass Memorial Medical Center in Worcester after nurses failed to respond to an alarm that sounded for about 75 minutes, signaling that her heart monitor’s battery needed to be replaced. The battery died, so no crisis alarm sounded when Warner’s heart failed.

Three of the cases involved alarms for a low battery or other malfunction that went unnoticed or were ignored.

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May 2007 - A patient’s heart stopped at Brigham and Women’s Hospital in Boston after nurses did not respond to a lower-level alarm signaling an unknown mechanical problem that may have been a disconnected lead or a low battery. The problem caused the monitor’s crisis alarm not to sound.

August 2007 - A patient died at Cambridge Health Alliance when nurses mixed up his cardiac monitor with another patient’s. As a result, caregivers mistakenly thought the patient was suffering a dangerous heart rhythm and treated him with a strong medication to slow his pulse, which contributed to his death. The man who was suffering the arrhythmia survived.

July 2008 - A patient at New England Sinai Hospital in Stoughton died after a cardiac monitor lead had fallen off his chest. Nurses did not hear the leads-off alarms because the volume was low, and staffers were meeting in the nurse manager’s office. Hospital investigators never discovered who turned down the volume.

September 2008 - At Tobey Hospital in Wareham, Edward Harrigan’s electrocardiogram displayed a “flat line’’ for more than two hours because the battery in his heart monitor had died. While nurses checked on him, no one changed the battery, so no alarm sounded when Harrigan, 87, suffered a heart attack.

January 2009 - At St. Elizabeth’s Medical Center in Brighton, a patient’s monitor cable became loose and the machine repeatedly sounded a low-pitched beep. Nurses said they didn’t hear the alarm. They didn’t discover the patient had stopped breathing until it was too late.

January 2009 - Linda Knyff, 47, died at Massachusetts General Hospital in Boston after the tube that had been surgically inserted into her trachea to help her breathe became dislodged. Because of an apparent malfunction, her cardiac monitor was not setting off alarms at the central monitor at the nurses’ station. Nurses would have been alerted to the malfunction by icons and alarms on the central monitor and on hallway signs.

January 2010 - An 89-year-old man died at Mass. General. Ten nurses on duty could not recall hearing the beeps at the nurses’ station or seeing scrolling ticker-style messages on three hallway signs that would have warned them as his heart slowed and finally stopped over a 20-minute span.

August 2010 - A 60-year-old man died at UMass Memorial after alarms signaling a fast heart rate and potential breathing problems went unanswered for nearly an hour.

September 2010 - A patient died at North Adams Regional Hospital after nurses didn’t respond to a leads-off alarm, which sounded softly. The patient, who came to the emergency room for stomach pain and symptoms of alcohol withdrawal, was found unconscious by a physician.

Executives at all the hospitals where alarm-related deaths occurred said they have made significant improvements in how they monitor patients, including educating nurses about the importance of responding to all warnings, checking batteries every morning, buying more expensive leads that do not slip off skin as easily, and making leads-off alarms more piercing - and hopefully more noticeable.

Liz Kowalczyk can be reached at kowalczyk@globe.com.
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