Death at UMass Memorial: Is the Problem “Alarm Fatigue,” or Something Bigger?

Last week, the Boston Globe reported on the second death in four years at UMass Memorial Medical Center related to “alarm fatigue.” Anyone who works in a hospital, particularly an area like an emergency department where critical patients are seen, can understand how a tragedy like this happens. Monitor alarms go off all the time. The question is whether it’s something critical or whether a lead just popped off a patient’s chest. Most of the time it’s the latter. 

But the tragedy speaks to a larger problem in health care. One of the most worrisome problems is the sheer number of regulations that my nursing colleagues must document and incorporate, which have very little to do with patient care. Domestic violence, for example, is an important issue, but having to document it on every patient that enters the ER takes away from performing the critical functions of triage and emergency care. When the documentation of restraints, fall risk, safety and need for a flu shot cause a nurse to miss a critical medication or assessment, something is wrong with the system.

It’s not that the regulations aren’t valid on their own. The issue is that we continue to add tasks to a workload and expect that each one will still be performed flawlessly. When that happens, we lose sight of the most critical functions of care. We set up the system for failure. When providers are disciplined for not following yet another rule, who is to blame? The provider or those who continued to add rule after rule?

Many manufacturing businesses talk about the lean principles, essentially designed to generate efficiency and increase productivity. Lean manufacturing considers the expenditure of resources for any goal other than the creation of value for the end-customer to be wasteful, and thus a target for elimination.

What we need is a lean for the numerous regulations, rules and required documentation that have accumulated in healthcare. Patient safety is one thing. When we lose sight of the critical functions providers are to perform, the result is patient harm and potentially preventable deaths. Whether it’s from alarm fatigue or something else, there is a larger issue at play.