Tuesday, April 06, 2010

Alarms should go off in our heads

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.


Anonymous said...

When I first read the article yesterday I was puzzled. Maybe I'm outdated, but my hospital used to have dedicated monitor techs. (e.g. their job was to sit there and monitor the monitors at the nurses station.) Are they a victim of budget cuts these days?


Unknown said...

20 years ago I worked as a nurse on one of the 40 bed medical units in what was then Beth Israel Hospital. The size of the unit, which was arranged in a star- like pattern of very long hallways around a central nurses' station, created plenty of patient safety issues. But never in my almost 5 years there was "alarm fatigue" regarding the telemetry system an issue. No matter how noisy the unit got, if one of those alarms sounded, a nurse would immediately review it and another would immediately go to check the patient if there was any question of safety.

Anonymous said...

From Facebook:

Scott: I think hospitals also lag behind in talent management, as evidenced by ads for health IT personnel with minimal qualifications.

Or no qualifications. From a "Healthcare Informatics"article "Who's growing CIO's" a few years ago:

... I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman.

Anonymous said...

"They don't think of the business issues at hand because they're consumed with patient care issues,"

That last guy is a real pip.

Yvonne MD said...

I to took from the articles I read on this that there was no central monitoring station. What happened to those? They used to be the standard of care. Did they go the way of budget cuts and new technology. If so, simple understanding of human behaviour could have warned before hand that this would happen.

S Daniels said...

Process improvement is not rocket science. There is no reason why delivery of care systems can't be improved except for the usual institution inertia that pervades most American hospitals.