Alert fatigue leads to fatality in OR
Alert fatigue can lead to behaviors in health care that may seem fine until the day they cause a tragedy, says John Banja, PhD, assistant director for health sciences and clinical ethics at Emory University in Atlanta.
Banja was involved in the investigation of a sentinel event involving a patient who died in surgery. The patient was undergoing an abdominal surgery, and the operating room team had turned off all the alarms on the equipment, because they found them annoying, mostly because they went off too often, at too low a threshold. They had done this many times before with no negative consequences, Banja says.
The procedure was proceeding well, and at one point the physician needed to obtain an X-ray of the patient's abdomen.
Because the patient's breathing would blur the X-ray, the surgeon asked the anesthesiologist to turn off the respirator while the X-ray was taken not an uncommon request. The anesthesiologist turned off the respirator and the X-ray was made.
The procedure continued, but the anesthesiologist never turned the respirator back on. Because the alarms on the respirator, and everything else, were turned off, no one realized the patient was suffocating until it was too late.
"The patient was left in a vegetative state and died 11 days later," Banja says. "Here was a catastrophe that happened because of the way that a defense mechanism had been disabled in this hospital. The anesthesiologist make a slam-dunk error, but if the alarms had been functioning, they would have caught that error immediately and you wouldn't have this horror occurring."
Alert fatigue can lead to behaviors in health care that may seem fine until the day they cause a tragedy, says John Banja, PhD, assistant director for health sciences and clinical ethics at Emory University in Atlanta.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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