The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery.
Schmid F, Goepfert MS, Kuhnt D, et al. The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery. Anesth Analg. 2011;112(1):78-83. doi:10.1213/ANE.0b013e3181fcc504.
Anesthesia equipment alarms went off approximately once per minute during cardiac surgical procedures; however, 80% of these alarms had no clinical consequences. The difficulty of calibrating alarm systems was discussed in an AHRQ WebM&M interview with human factors engineering expert Donald Norman, PhD.