An ESRD patient was having his regularly scheduled dialysis session. Since he would be in the dialysis center for several hours, he was in a comfortable lounge chair that tipped back. Also, since it was somewhat cool, he was offered a blanket to keep warm.
Midway through the dialysis session, the low-pressure alarm rang. The nurse turned off the alarm and eyeballed the patient and saw no blood. Nothing further was done. Soon thereafter the low pressure alarm triggered again. This time it was recognized that the dialysis catheter had become dislodged and the patient had, in fact, had considerable blood loss. It had not been appreciated immediately because the blanket had been covering up the catheter site and the blood, rather than being visible on the floor, had been pooling in the webbing of the lounge chair.
Anyone who has ever spent time in an ICU or other hi tech medical environment knows that the usual response to an alarm is to turn the alarm off. Proper design of medical equipment therefore should force the responder to focus on the source of the problem. In the case at hand, the equipment and alarm were on the side of the patient opposite from the involved limb so that the visual attention of the responder was not directed immediately to the site the alarm was drawing attention to.
My copy machine tells me exactly where to look when there is a paper jam. Why can’t critical medical monitoring devices do the same thing?!!! Proper design of medical equipment necessitates seeing how humans will respond to it in the typical medical setting. When Microsoft develops new software, it puts real people in a real-life setting and sees exactly how people are likely to respond to various scenarios. Why can’t all medical device manufacturers learn from this?
Unfortunately, you all have lots of equipment that have alarms that don’t make the responder focus directly at the problem. Faulty response to alarms is one of the “big 3” problems encountered in many root cause analyses of sentinel events. Performing FMEA (Failure Mode and Effects Analysis) is a good way to help anticipate events that might arise in your critical settings.
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”