Heart patient dies after alarm turned down

Some may have seen this sad story in the papers this week - http://www.metro.co.uk/news/867880-patient-dies-after-staff-turn-down-volume-on-heart-monitor-alarm - of a patient who died after staff apparently turned down the volume on the heart monitor and failed to see the flashing warning light until it was too late.

The story highlights a number of broader issues.  Firstly is designing to prevent people from being able to take undesirable actions such as turning down the volume on the monitor.  Second, is designing to understand human behavior - was it that the alarm sounded too loudly in relation to the normal background noise levels or there were false alarms that led to the staff turning it down?

Finally is the need to look at the design with different perspectives.  The designer of the heart monitor would probably not have been able to foresee that not only would the alarm be turned down but the speakers would be turned around and paperwork put against them.  So the design process for implementation needs to consider the environment into which the system is being put and how it will be used.  This is something that Ergonomists and Human Factors Engineers are good at and have a role to play