There is a quote about telemetered alarms that caught my attention in a recent Boston Globe story by Liz Kowalczyk about one of the Boston hospitals:*
“If you went to any hospital floor in America where there is monitoring and asked the doctors and nurses, they would say there are too many alarms and too much background noise,’’ said Dr. Gregg Meyer, senior vice president for quality and patient safety.
Gregg is excellent at his job, and I believe him to be correct on this point. Hospital people around the country would likely admit him to be correct, too. We found that to be the case in our hospital and, like MGH, made some changes in our use of telemetry as a result.
This is a classic problem in human factors engineering. There is a recent article on the topic by Heather Comack at Health Leaders Media.
As in other complex settings like power plants, safety systems are often added in response to sentinel events that have occurred or because of regulatory concerns. But the addition of safety systems carries the risk that those systems themselves cause new safety problems to arise.
I am sorry to say that this is yet another area in which the hospital world is woefully behind other industries. We lag in understanding how to undertake process improvement and in training our medical staff to understand care delivery systems, but we fall even farther beyond when it comes to human factors engineering.
Maybe Don Berwick can use some of his knowledge and skills at CMS to help move this along, but I think he can only nudge. Change must come from within the hospitals themselves, but we need to be modest about what we know and borrow shamelessly from other industries.
*I mean in no way to cast aspersions about a sister institution by writing this post. BIDMC has been through a similar regulatory review to that described in the article, by the way, but related to other types of issues. The topic raised in the Globe article has broad implications for all institutions, and that is why I write today.