Failure to Rescue from Cardiac or Respiratory Arrest
When our loved ones are admitted to hospitals, we expect the doctors and nurses will be prepared for the worst. When we review medical records which paint the picture of disability or loss of life due to cardiac or respiratory arrest, we learn the story often begins with the same setting – a patient suffers a predictable cardiac or respiratory arrest, but caregivers fail to recognize the patient isn’t breathing, or their heart no longer beating. Nobody realizes the patient who was once alert and talking with others is suddenly non-responsive. A response to such an emergency is dangerously delayed because monitoring necessary to assure immediate action and save lives, is never provided, or simply ignored.
The American Association of Critical Care Nurses reports the number of alarms in an intensive care unit setting increased from an average of 6 in 1983 to over 40 different alarms as of 2011. The Association also reported 80 to 99% of EKG alarms are false or of no significance to the patient. (Sendelback & Jepsen, 2013).
Forced to listen to a discordant orchestra of alarms, the most of which are merely an annoyance, it is no wonder why apathy sets in when nurses hear an alarm. Still, with no way to discriminate between a “false alarm” and an emergency, caregivers should never ignore an alarm on a heart or oxygen monitor.
The Joint Commission, an independent, not for profit organization which accredits and certifies nearly 21,000 healthcare organizations across the country, recognizes the chaos caused when numerous alarm signals and the resulting noise desensitize members of the hospital staff and cause them to miss or ignore alarm signals or even disable alarms. Effective January 1, 2016, the Joint Commission’s National Patient Safety Goals require hospitals who wish to remain accredited make alarm safety a priority by doing the following:
- Identifying which of the many alarm signals are the most important to manage. This requires hospital leaders look to published guidelines and input from staff to identify which alarms which left unheeded or malfunctioning pose the greatest risk of harm to patients.
- Establish policies and procedures for managing alarms, including policies that address clinically appropriate settings for alarms, who can disable an alarm and when, who can change the parameters of an alarm and when, and how caregivers must monitor and respond to alarms.
The attorneys of Lupetin and Unatin have the knowledge and desire to determine why abnormal EKG tracings, glaring alarms from a monitor, or other signs of an emergency remain unheeded. Some of the issues important to solving the mystery of why some patients suffer needless delay before resuscitation from cardiac arrest include the following:
- Did the hospital fail to provide heart or oxygen monitoring where it was indicated for the patient’s clinical situation?
- Whether or not the unit where the incident occurred was staffed by dedicated monitor watchers, and if so, how was the responsibility to monitor the EKG divided between nursing staff and the monitor watchers;
- What if any procedures were in place in the hospital with respect to the clinical parameters for alarm settings, e.g. were alarm settings properly modified to the individual patient, or were settings improperly altered to avoid triggering the alarm for patients whose heart rate or oxygen levels are “always on the low or high side”?
- Was there a nurse specific or unit-wide practice with respect to disabling alarms?
- Whether nursing staff misinterpreted or failed to interpret abnormal heart rhythms.
When a patient attached to a machine designed to detect the warning signs of cardiac or respiratory arrest suffers the very event for which this machine was designed to detect, and that event goes unwitnessed, no explanation will suffice. It is regrettable, but reality that nurses intentionally disable alarms or change alarm settings in direct ignorance of parameters that are predetermined and designed to assure the safety of patients.
If you or a loved one was recently admitted to a hospital and suffered injury which you feel was preventable, allow our attorneys to determine whether the hospital failed to take necessary safeguards to protect the patient from harm.