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November 11, 2013

How 'alarm fatigue' may have led to one patient death

Daily Briefing

    A patient died at a Des Moines hospital earlier this year after a nurse turned off all his patient monitoring alarms, the Des Moines Register/USA Today reports. The nurse said later that the alarms were always going off, even when the patients were healthy.

    Alarm-ing trend: Patients continue to suffer as nurses tune out beeps, alerts

    According to records recently disclosed to the public, Army veteran Michael Deal died March 29 at the VA Central Iowa Healthcare System hospital hours after RN Bernard Nesbit turned off the alarms. One of the alarms was set to alert staff to any drop in the patients' blood-oxygen levels and when Deal was found dead, his blood-oxygen levels had fallen to a dangerously low level.

    Subsequently, Nesbit was fired.

    Under oath: Nesbit testifies about incident

    At a recent public hearing, Administrative Law Judge Teresa Hillary asked Nesbit if he had shut off the alarms. Nesbit initially answered, "I very well could have." When asked again, he responded, "Yes," adding that the alarms were always going off.

    In an email to the hospital, staff member Daryle Jager described how he had found Deal "unresponsive, ashen, pale, cyanotic and unresponsive." When staff checked the patient monitors, they found that all of the units' alarms—including the alerts for several other patients—had been shut off for three hours.

    HR spokesperson Greg Smith testified that staff members were not sure if an "intervention would have made a difference," but Deal's respiratory therapist Jason Swenson argues that "numerous interventions" could have prevented his death.

    Judge Hillary denied Nesbit's request for unemployment benefits, saying the evidence was "overwhelming" that he had shut off the patient alarms (Kauffman, Des Moines Register/USA Today, 11/6).

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