Alarm Fatigue Lawsuit Over Cardiac Monitor Settled

MGH patient died despite alarms

By Liz Kowalczyk | The Boston Globe
November 28, 2011

The family of a man who died at Massachusetts General Hospital when nurses did not respond to alarms on his cardiac monitor—a death that focused national attention on the dangers of “alarm fatigue’’ among hospital staff—settled its case against the hospital for $850,000.

See follow up on this story:
Alarm Fatigue Issue Gets FDA Attention
on our Patient Safety Blog. 

Mass. General and the patient’s family reached an agreement in May, but the private settlement was never filed in court and the parties have not discussed it publicly until now.

“Much to Mass. General’s credit, they recognized the error and tried to do right by the family,’’ said their lawyer, Boston attorney Andrew Meyer. “They are in good faith trying to prevent the problem from occurring in the future. The family was appreciative.’’

The malpractice insurer for Harvard teaching hospitals reached the settlement on behalf of Mass. General and the doctors and nurses involved in the man’s care. The patient’s family did not want him to be identified by name because of privacy concerns.

The patient, who was 89, had a history of heart problems and was recovering from surgery and awaiting implantation of a permanent pacemaker on the morning he died in January 2010. According to state and federal investigators, 10 nurses on duty could not recall hearing the beeps at the central nurses’ station or seeing scrolling ticker tape-style messages on three hallway signs that would have warned them as his heart rate fell and finally stopped over a 20-minute span.

Investigators concluded that alarm fatigue experienced by nurses working among constantly beeping monitors contributed to their inattention. Additionally, the volume for a separate audible crisis alarm on his bedside monitor had been turned off.

Although monitors can save lives when they alert nurses to dangerous changes in a patient’s condition, most alarms are false, triggered by patients shifting in bed or minor changes. According to a Globe investigation published earlier this year, repeated false alarms can desensitize nurses, causing them to tune out alarms that turn out to be critical—a phenomenon called alarm fatigue linked to hundreds of patient deaths.

The Globe first reported the man’s death in February 2010. In April 2010, Dr. Gregg Meyer, the hospital’s senior vice president for quality and safety, wrote the family a letter of apology, saying staff was devastated because “we know that we let him and you down in our care.’’

In the letter, Gregg Meyer, who is not related to Andrew Meyer, said the hospital conducted an internal investigation that led to improvements, including disabling the off switches on 1,100 cardiac monitors, educating nurses on general-care floors about alarms and responding to them quickly, and installing more speakers so alarms can be heard clearly. He told the family that neither they nor their insurance company would be billed for the man’s care.

“We learned a lot of very hard lessons from that case,’’ Gregg Meyer said in an interview.

The case and the Globe stories have spurred the industry to examine the problem of alarm fatigue more closely. Both the Joint Commission, which accredits hospitals, and the US Food and Drug Administration, which regulates monitor manufacturers, participated in an alarm summit near Washington, DC, last month and are expected to take action to address the problem.

In a separate case, the family of another patient who died at Mass. General in a monitor-related incident in January 2009 sued the hospital in Suffolk Superior Court earlier this month. That patient, Linda Knyff, 47, died after she was found unconscious and without the tube that had been surgically inserted through her neck and into her trachea to help her breath.

The state Department of Public Health, which investigated the case, found that the patient’s cardiac monitor was not setting off alarms about the patient’s condition at the central monitor at the nurses’ station. A breakdown in communication occurred between nurses and biomedical engineers about whether the malfunctioning monitor had been replaced, with nurses apparently believing it had been, according to the state report.

Nurses would have been alerted to the malfunction by icons and alarms on the central monitor and on hallway signs, the report said. But at least two nurses were not familiar with how these alerts worked. In response, the hospital developed a training program for nurses, among other improvements.

Knyff’s mother, Rosemarie Milana-Tedesco of Tewksbury, who filed the lawsuit, said she was upset about what happened. In a meeting soon after her daughter died, Mass. General staff members told her the monitor had malfunctioned and promised to repair the problem, Milana-Tedesco said in an interview. Andrew Meyer, who is representing this family as well, said hospital staff failed to replace a monitor they knew was broken.

Although monitor problems played a role in this case, Gregg Meyer said the cause of the patient’s death was more complicated than that of the man who died in January 2010.

The health department report said the patient had been extremely restless and continually pulling out her tube and had to be restrained at various times.

Nurses who found Knyff also initially inserted an emergency breathing tube incorrectly.

Gregg Meyer said there are many different types of monitor failures and this case shows that hospitals need to take a comprehensive approach to addressing technology hazards.

Return to News index