[btach]

Anecdote: At an ED I used to work at, our cardiac monitors got "upgraded" to another manufacturer. Silencing false alarms was a black hole of a game of whack-a-mole. You could never silence them all, another would just pop up to spite you. Anyway, one night, it was continuing to alarm and being ignored (with a glance occasionally to make sure). Except somebody was in v-tach and the person who noticed was a medic bringing a patient in. Thank goodness they noticed amid the noise! (We had as good of outcome as could be expected with that patient, and they went to the cath lab and lived).

[dmurray]

What would have happened if the medic didn't notice and the patient died? Would you have got the blame for ignoring it, or management for creating a situation where you had no choice but to ignore some alarms because of false positives, or the manufacturer, or would it have been swept under the rug as "the patient was having heart failure and unfortunately even our state-of-the-art medical care couldn't save him"?

All of those sound superficially plausible to me, although I have my ideas on which are more likely... Would you even do an, um, incident post mortem for something like that or would it just be a statistic?

[btach]

There would definitely be an investigation, as all sentinel events are investigated. Management would do their RCA and I'm sure the issue with alarm fatigue would be ignored or underplayed (Something bad happen? make sure an alarm sounded. If staff ignored it, it must be the fault of the staff). I doubt any one person would be in trouble as it was a collective/systemic failure, but I don't know exactly what would have come of it. Likely a policy change or daily reminders for the next few weeks about not ignoring the monitors even if it has been going off nonstop for hours. Maybe extra charting or peer audits. It's a lot less expensive and effort to put pressure on staff than it is to change technology (even if it is as little as setting different, more sane, defaults). Depending on what was recorded from the monitor to the chart, if it looked like there wasn't a delay in resuscitation/cardioversion (like if the lethal rhythm wasn't recorded initially), it may have been just put down as clinical course for the patient, like you suggested. My perspective of that place is a bit jaded (and therefore biased), that place was a toxic burn-out factory. BTW, "post mortem"? Thanks, the morbid humor made me laugh!

[LorenPechtel]

They will try as hard as they can to pin system failures on the unfortunate person who was in charge of the system.

Or, a local case, the nurses were complaining about shoddy supplies. Eventually the holes in the swiss cheese lined up and a baby died. The hospital tried to treat it as a murder by the nurse. (Claiming the line was cut, rather than it broke.)