how automated healthcare fails, how you'd know, and what to do at each tier — every claim sourced, reviewed continuously
A patient on a cardiac monitor died after the monitor's crisis alarm had been left off; lower-level alarms sounded at the nurses' station but went unheeded.
LimitationBoth sources are Boston Globe reports. The state investigators' findings are known here only as the Globe quotes them; no CMS or state inspection record was found online.
TierNo loss of automation: the monitor worked, but its crisis alarm was switched off and lower-level alarms went unheeded. How tiers are assigned.
The Boston Globe reported in February 2010 that a Massachusetts General Hospital patient had died the previous month after the crisis alarm on a GE heart monitor was inadvertently left off, delaying the response of nurses and doctors. Hospital leaders said they did not know why the alarm was off; a nurse found the patient in crisis on a routine check. Within a day the hospital inspected and disabled the off switch on all 1,100 of its heart monitors, and temporarily assigned a nurse on each unit to listen for alarms. A year later the Globe reported that ten nurses on duty that morning could not recall hearing the lower-level alarms at the central station, or seeing warnings on three hallway signs, as the patient's heart rate fell over about 20 minutes. It quoted state investigators: nursing staff said they were experiencing alarm fatigue and a desensitization to alarms. The investigators did not say why the crisis alarm was off.[1,2]
Death of the patient (Boston Globe).
All incidents · Human handoff · Devices
Information only, not advice. FailSystems is an aggregation and synthesis of published sources. It is not consulting, engineering, legal, regulatory or medical advice, and using it creates no professional relationship. Health systems are complex and no approach fits every organisation: anything you adopt is your own decision, at your own risk, and should be checked against the current official sources and by qualified people who know your setting. Full disclaimer.