[wux]

The problem, of course, is that elsewhere in the chain there was in fact too much checking and too little trust. In this case, it started with not trusting the physician to enter a known dose and requiring an unnecessary conversion, which kicked off the chain of events. This was immediately followed by the problem of alarm fatigue, where practically no set of medication orders can be entered without triggering a slew of useless automated warnings.

The problem of having to deal with too many alarms is not unique to the hospital system mentioned in this article. I discovered the other day that at least one model of ventilator has an alarm that sounds when any object sits in front of the display screen. There was a stethoscope dangling in front of a corner of that screen where nothing was displayed, and an alarm went off of approximately the same urgency as one that would sound if the ventilator were about to blow a patient's lungs out. The same alarm that goes off when a patient's heart rate goes from 60 to 250 bpm sounds when the patient's heart rate goes from 99 to 101 bpm. The pharmacist who was supposed to be checking my orders for sanity once paged me out of a patient room because he couldn't find the URL for the hospital's policy on titrating a particular medication, a document issued by the pharmacy. Most people would agree that it's insane to text and drive on the highway, and yet this is essentially what's being expected of every physician in every hospital while they're making major medical decisions.