A patient with asthma arrived mid-morning at an emergency room with status asthmaticus. Treatment was begun but the patient required intubation and mechanical ventilation. He was stabilized and the ICU was called to admit the patient. The ICU had no empty beds but told the ER that they expected a bed to open up shortly. The ER said the patient could stay on a ventilator in an ER room until that bed was ready. Respiratory Therapy evaluated the patient and hooked the patient up to a dual power-source portable ventilator. That was felt to be ideal for this patient because it could be used either with typical AC current in the ER or use its built in battery during transport.
A call to the ICU after an hour still found no available ICU bed. The ER now started getting busier but the patient remained stable on the portable ventilator. Unbeknownst to all, the circuit breaker on the AC wall source had tripped, so the portable ventilator was running on battery power. After 5 hours in the ER, the portable ventilator exhausted its battery power and ceased functioning. The patient had a respiratory and then cardiac arrest.
Investigation revealed that no staff had heard any alarms on the EKG monitor even though it was likely the patient would have developed tachycardia and/or bradycardia after the ventilator had ceased functioning. The alarm volume, in fact, had been turned down to a level barely audible even by those in the immediate room. The room was immediately adjacent to the nursing and secretarial work area and staff had turned down the alarm volume because it distracted them from work.
When the hospital team conducting the RCA investigation came to the ER to re-enact the events, they found that the volume on the same alarms had been turned down again. A similar visit done with the health department a week later again found the alarm volume turned down.
Avoiding the snap reaction to take punitive action against the staff member who had initially turned down the alarm volume, it became very clear that the root cause was a flawed design to the ER. That design obviously led to the practice of turning down the alarm volume. One wonders how many ER’s, ICU’s, etc. suffer from this same type of design flaw that promotes such an unsafe practice. I’m always amazed when a hospital administrator proudly states “we designed this unit to have full visual contact of all patients”, only to find that the very proximity led to this practice of lowering alarm volumes.
A second root cause was the development of a “culture” in the ER that tolerated manipulation of the alarms as an unsafe workaround.
Another root cause was in the design of the portable ventilator. How was one to know that it was functioning on battery power rather than AC power from the wall outlet? In fact, it did have an indicator light to flag which power source was being utilized. However, that indicator light was located on the back of the unit and not readily visible to staff in the room.
The case is also a good example of how technological “safety” advances may not actually reduce accidents, much like maritime radar simply encouraged ships to go faster. In this case, the “ideal” dual power-source ventilator fostered a false sense of security.
Lastly, the bottleneck caused by bed unavailability in the ICU was yet another root cause that led to implementation of a better system for triage of ICU beds.
A very unfortunate case but it illustrates multiple points that one often sees in cases with adverse outcomes (cascade of errors, latent errors, violations, unsafe workarounds, communication breakdowns, misuse of alarm systems, multiple design flaws, safety “culture” issues, bottlenecks and patient flow issues, and technological advances with unintended consequences).
Patient Safety Tips of the Week pertaining to alarm-related issues:
March 5, 2007 “Disabled Alarms”
March 26, 2007 “”
April 2, 2007 “”
June 19, 2007 “Unintended Consequences of Technological Solutons”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue”
November 2010 What’s New in the Patient Safety World “Alarms in the Operating Room”