Ventilator Errors Associated With 119 Nationwide Deaths From 2005-2011

An analysis conducted by the Boston Globe reveals that 119 patient deaths were linked to ventilator alarm errors from 2005-May 2011.

For its analysis, the Globe relied on adverse events reported to the U.S. Food and Drug Administration in the aforementioned time period. According to the report, approximately 800 adverse events associated with ventilator errors were reported to the agency in 2010 alone.


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A detailed break-out of the 119 deaths reveals the following:

•    Sixteen deaths were due to improperly set or used alarms.
•    In 27 deaths, caregivers were unable to hear or respond to the alarm in time.
•    In 53 cases, the caregivers reported the alarm did not sound.
•    In four cases, the caregiver silenced the alarm; and in six cases, the caregiver wasn't sure if the alarm sounded at all.
•    In two cases, the ventilator malfunctioned.
•    It is unclear what happened in 11 of the deaths.

The Globe's analysis highlights growing concern regarding "alarm fatigue," a phenomenon that occurs when nurses, bombarded daily by hundreds of machine alarms that alert potential patient crises, tune out the sound due to overexposure.

Related Articles on Alarm Fatigue:

ECRI Institute: 10 Most Hazardous Health Technologies

Frequency of False Alarms is Top Concern About Clinical Alarm Systems

Patient Deaths From 'Alarm Fatigue' a Nationwide Challenge

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