Chapter 16The Alerts

When the villagers saw no wolf, they sternly said, “Save your frightened song for when there is really something wrong!”

—Aesop, The Boy Who Cried Wolf

Computerized medication alerts represent only a small fraction of the false alarms that besiege clinicians each day. Barbara Drew, a nurse-researcher at UCSF, has been studying a similar problem, alarms in the ICU, for decades. During that time, she has seen them grow louder, more frequent, and more insistent. She has witnessed many Code Blues triggered by false alarms, as well as deaths when alarms were silenced by nurses who had simply grown weary of all the noise.

In January 2010, an example of the latter brought the issue of alarm fatigue to national attention. An 89-year-old ...

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