More than a hundred patients on ventilators have died since 2005 due to
medical errors involving the machines’ warning alarms, a new Boston Globe investigation
reports. According to the paper, a separate review by the US Food and
Drug Administration revealed about 800 alarm-related medical errors involving
ventilator patients in 2010 alone.
As San Diego medical malpractice attorneys, we are particularly concerned
because both reports suggest that many of the incidents were deemed “preventable’’
or due to “human error.’’
Below are some of the findings:
- Of the 119 cases, manufacturers found that caregivers did not hear or respond
to warnings in time in 27 instances, and improperly set or used alarms
on 16 occasions.
- In six cases, caregivers didn’t know whether the ventilator alarm
- In four cases, someone silenced the alarm without addressing the problem;
and in 11, it was unclear what happened. In just two cases was there a
clear malfunction of the ventilator.
- In 53 of the cases, caregivers said the ventilator alarm did not go off.
- While ventilators sometimes are recalled because machines do not work properly,
in many of these 53 cases, manufacturers who investigated the complaints
found the alarms worked fine.
As we noted in a previous blog post, nurses and other caregivers can become
desensitized to audible warnings from medical devices, a phenomenon known
as alarm fatigue. As evidenced above, this likely plays a part in many
ventilator-related medical errors.
Ventilators sound alarms when the breathing tube has become disconnected
or plugged with mucus, cutting off air to the patient; when the air pressure
is too high or too low; or when the ventilator simply stops for some reason.
All of these require immediate attention by a health care professional.
Alarms are clearly beneficial when they alert nurses to a serious change
in a patient’s condition, but they also can “lull people into
a false sense of security,’’ said Sam Giordano, chief executive
of the American Association for Respiratory Care, a nonprofit professional
society based in Texas.
“The alarms are a symptom, and it’s up to the caregivers to
sort out whether that requires medical intervention,’’ he
said. “Sometimes we overdo it and forget we’re there to watch
that patient. We can’t send in alarms to replace the caregivers.’’
If you or someone you love has suffered from a medical error, contact
the Law Offices of Robert Vaage for
a free consultation.