The following scenario is derived from incidents reported to
A stable, ventilator-dependent patient (KP) was placed in a
room across from the nurses’ station. The nurse caring for this
patient then received a post-operative patient whose condition
was deteriorating. A code was called for the post-op patient and
several staff in the area responded to assist. During this
emergency, KP’s ventilator tubing had become disconnected and the
ventilator starting alarming. However, no one responded to the
alarm until a custodian passing by approached the nurses’ station
and notified the unit clerk that he had noticed an alarm coming
from KP’s room for several minutes and wanted to make sure
someone was notified. At this point, the clinical staff realized
that KP was quickly deteriorating and immediately responded.
Unfortunately, they could not resuscitate KP.
Diffuse responsibility is a recognized safety concern in clinical
alarm management. In order to manage the large amount of noise in
busy and monitored environments, clinicians often “tune out”
alarms that are not related to their own patient assignment.
There is an underlying assumption that someone else is responding
to an alarm associated with another clinician’s patient.
Personnel in the area who are not clinicians are intimidated by
alarms and assume that a clinician will respond. One approach to
solving this issue is to implement the “No Pass Zone.”