In April 2013, a Sentinel Event Alert provided by The Joint Commission cited 98 alarm-related events over a 3 ½ year time frame. It reported 80 of those events actually resulted in death and 13 caused permanent loss of function. This was a result of “alarm fatigue;” a new phenomenon characterized by caregivers becoming overwhelmed, distracted or desensitized by the large number of physiological alarms generated by modern monitoring systems. In fact, a recent study reported by the American Nurses Association shows that, in a single month, there are more than 2.5 million alarms triggered on bedside monitors!
Medical device alarms aid in timely, life-saving interventions that have been instrumental in improving patient outcomes. However, as discussed in my last blog, technology is not foolproof. In nursing school, we teach, “treat the patient, not the machine.” Current monitoring systems do not take into account differences between patients. There is not a “one size fits all” setting and this can lead to many clinically insignificant alarms. As a result, alarms are sometimes disabled, silenced or the volume is turned down to an inaudible level. Obviously, this increases the risk for missing an important alarm that could potentially make a difference between life and death.
Medical device alarms aid in timely, life-saving interventions that have been instrumental in improving patient outcomes. However, as discussed in my last blog, technology is not foolproof. In nursing school, we teach, “treat the patient, not the machine.” Current monitoring systems do not take into account differences between patients. There is not a “one size fits all” setting and this can lead to many clinically insignificant alarms. As a result, alarms are sometimes disabled, silenced or the volume is turned down to an inaudible level. Obviously, this increases the risk for missing an important alarm that could potentially make a difference between life and death.
There are a variety of medical device alarms in a hospital to inform about changes in a patient’s status or circumstance that could adversely affect the patient’s care. For example, physiological monitors will alarm when a patient’s heart rate, blood pressure or oxygenation falls outside of specified parameters. Ventilators will alarm when breathing circuits become disconnected. Infusion pumps will also alarm when an IV solution runs out or when there is air in the IV line. These examples all necessitate an action by a healthcare worker in a timely manner.
Nevertheless, there are also many alarms for conditions that may not be as clinically significant. For example, an alarm warning when an EKG electrode has poor contact with the patient’s skin or an alarm warning when a patient bends his arm to eat something because it momentarily occludes the IV line. Minimizing the number of clinically insignificant alarms can facilitate better recognition of conditions that truly require attention.
Any failure for staff to be informed of a valid condition in a timely manner or failure to take necessary action to an alarm can be considered an alarm hazard. As a result, The Joint Commission announced a new National Patient Safety Goal (NPSG.06.01.01) on clinical alarm safety. Hospitals will be expected to develop and implement policies and procedures for alarm system management as well as provide staff education no later than January 1, 2016.
Nevertheless, there are also many alarms for conditions that may not be as clinically significant. For example, an alarm warning when an EKG electrode has poor contact with the patient’s skin or an alarm warning when a patient bends his arm to eat something because it momentarily occludes the IV line. Minimizing the number of clinically insignificant alarms can facilitate better recognition of conditions that truly require attention.
Any failure for staff to be informed of a valid condition in a timely manner or failure to take necessary action to an alarm can be considered an alarm hazard. As a result, The Joint Commission announced a new National Patient Safety Goal (NPSG.06.01.01) on clinical alarm safety. Hospitals will be expected to develop and implement policies and procedures for alarm system management as well as provide staff education no later than January 1, 2016.
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