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PSNet: Patient Safety Network
Journal Article

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. Anesthesia and analgesia. 2011;112:78-83.

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.