Examples of Inefficient Alarm Management

 In Alarm Management

Since 2003, the Joint Commission has advocated for improved clinical alarm systems, consistently ranking it sixth among its most important National Patient Safety Goals. In fact, despite being retired from the list in 2005 and incorporated as a standard, issues concerning alarm safety only continued to grow until alarm management was added back as a priority to the the list in 2014. The Emergency Care Research Institute, a nonprofit organization that serves to research the best solutions to patient care, has ranked alarm hazards as its top patient safety concern since 2013.

Specific Cases of Inefficient Alarm Management

Disturbing reports from the Boston Globe and other publications have made light of multiple deaths resulting from alarm fatigue and inefficient alarm management. In one of the most publicized incidents occurring in 2010, a cardiac patient at Massachusetts General Hospital passed away after his heart rate fell and a series of beeping alarms carried out over a period of 20 minutes were ignored  by nurses.  When Medicare and Medicaid professionals investigated further, they found that a crisis alarm at the patient’s bedside had been turned off unknowingly. However, while ten nurses nearby denied hearing any alarms sounding off, investigators attributed the lack of awareness about the nearby  alarms and medical tickertape reporting the patient’s vitals to alarm fatigue.

Furthermore, a year later, the Pennsylvania Patient Safety Authority found that over a 6 year period tracking 187 patients who died while being physiologically monitored, 35 died from issues involving human error.  After a dismal incident in 2012, in which the parents of a 17-yr-old girl who had died following her tonsillectomy because a heavy painkiller had dangerously slowed her breathing without nurses taking note received a $6 million dollar malpractice settlement, the responsible Pennsylvania surgery center decided that nobody could have the authority to mute any more alarms. Yet, while this action may have given the bereaved parents some satisfaction, it actually did nothing to solve the problem on hand: alarm fatigue, the condition in which nurses become desensitized to or overwhelmed by the barrage of alarms they’re subjected to everyday.

Alarm Safety Becomes a Top Concern for Hospitals

Since then, a host of recent studies has helped to bring clinical alarm safety to the forefront of hospitals’ concern. In January 2014, the Boston Medical Center conducted a six-week study in which they drastically reduced the number of warning alarms by tailoring the alarms to fit patient needs and, in some cases, changing the status to “crisis” alarms, which require immediate action. In doing so, the number of alarms dropped by around 89%, decreasing from 12,546 alarms per day  to 1,424 alarms daily.

Additionally, the Children’s Hospital of Pennsylvania conducted a novel study in 2014 in which they used a video-based approach to monitor various patient alarms and the length and suitability of nurse responses instead of shadowing nurses to judge the effects of alarm fatigue. Through 210 hours of observation reviewed by multiple researchers, an analysis of 4, 962 alarms found that 99% of alarms in ward patients’ rooms and 86.7% of alarms in heart and lung failure patients’ rooms was classified as false (didn’t warrant a clinical intervention from nurses).

Footnotes:

1- http://www.jointcommission.org/assets/1/6/2015_NPSG_CAH.pdf

2- http://www.jointcommission.org/assets/1/6/Perspectives_Alarm.pdf

3- http://www.washingtonpost.com/sf/feature/wp/2013/07/07/too-much-noise-from-hospital-alarms-poses-risk-for-patients/

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