A Death Spurs Action At MGH

Sadly, it often takes a tragedy to focus attention on a long-simmering problem and do something to fix it. Liz Kowalczyk, of The Boston Globe, reports today on the death of a patient at Massachusetts General Hospital, whose heart monitor was inadvertently left off, thereby delaying a timely response from nurses and doctors during a medical crisis.

According to the report, MGH immediately launched an investigation into the matter and staff inspected and disabled, "the off switch on alarms on all 1,100 of Mass. General’s heart monitors."

Still, fatal incidents involving patient monitoring devices are, apparently, not uncommon, Kowalczyk writes:

Patient safety officials said the tragedy at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because alarms malfunctioned or were turned off, ignored, or unheard.

“This is one of the most frequent and serious problems we see,’’ said Jim Keller, a vice president for ECRI Institute, a nonprofit research and consulting organization based in Pennsylvania that specializes in medical devices. On its top 10 list of health technology hazards last year, it listed alarms on patient monitoring devices as number two.

The Joint Commission, an Illinois-based organization that inspects and accredits hospitals, said it also has seen a surge in alarm-related incidents.