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Alarms can become mere noise disassociated with the meaning behind the alert. Back in the Spotlight A adverse event in Massachusetts is largely responsible for bringing alarm safety back into the spotlight Cvach. The patient, an year-old man, was on a cardiac alarm, and over 20 minutes, his heart rate slowed and stopped. Investigation of the event determined that the volume on the alarm was turned off and, further, that the volume settings could be easily and inadvertently modified by staff, most of whom were not aware of this feature. Another recent case serves as a reminder that alarm safety is not only a concern in the hospital environment. She experienced respiratory depression followed by respiratory arrest, suffered profound brain damage, and died. Investigation revealed that not only was the patient left unobserved for 25 minutes after administration of the fentanyl but also that the alarms monitoring her respiration and cardiac function were muted.


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