Clinical alarms hazards threat hospital settings. There were “566 deaths related to monitoring alarms” reported from a separate Manufacturer and User Facility Device Experience (MAUDE) database (Cvach, 2012, p. 269). Pelletier (2013) reported one of the biggest contributing factors to patient deaths was related to “alarm fatigue” (p. 292). The purpose of this paper is to review research and explore best practices to support alarm management and the prevention of alarm fatigue and patient harm.
Welch (2012) reported nurses comparing patient care areas to that of a “carnival or casino” (p. 1). Edworthy (2013) found in clinical telemetry settings, the presence of false alarm rates were “unacceptably high” and “proper application of auditory alarm principles were compromised” (p. 1). According to the American College of Clinical Engineering (ACCE) Healthcare Technology Foundation (2011), alarm fatigue occurs when “too many alarms occur in a clinical environment” (p. 1). When challenged with hundreds of alarms in a patient care day, a reported “five percent represent a true required clinical intervention” (American College of Clinical Engineering (ACCE) Healthcare Technology Foundation, 2007).
The Joint Commission has recognized the urgency by addressing safety of alarm systems. In April 2013, Sentinel Event Alert, the Joint Commission reported 98 alarm related events (JACHO, 2103). Of these 98 events, 80 of them lead to death, and 13 resulted in permanent loss of function (JACHO, 2103). A new patient safety goal for 2014 goal is to improve the safety of clinical alarms. Elements of performance include setting alarm management as a priority. This includes the establishment of policies and procedure for the management of ...
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...orthy (2012) completed a narrative review. This article was not classified as a systematic nor integrative, although the research was comprehensive. Edworthy (2012) completed a review including many of the traditional medical literature databases such as PubMed and Web of Knowledge. She additionally searched in the PsychINFO and human factor journals. Her strategy was to examine the available research specific to auditory alarm response time. Fifty eight articles were cited in this review. This article represented a comprehensive narrative by an expert in the specialty area. The author had twenty-five years experience as a researcher and designer in the area of audible alarms. Her findings suggested a significant improvement in response to alarms when greater emphasis is placed on the alarm design (Edworthy, 2012). She recommended standardization of alarms.
On May 20th, the patient, Mr. Ard, experienced nausea, shortness of breath, and pain while being treated in the hospital (Pozgar, 2014). The patient’s wife, Mrs. Ard, attempted many times to reach a nurse by pressing the nurse call button (Pozgar, 2014). Once the nurse finally responded, anti-nausea medication was administered (Pozgar, 2014). Mrs. Ard continued to monitor her husband’s situation, and felt as if the nausea and shortness of breath were getting worse (Pozgar, 2014). Mrs. Ard continued to ring the nurse call button for approximately 1.25 hours prior to a response from a nurse (Pozgar, 2014). A code was called, and Mr. Ard did not survive (Pozgar, 2014).
When the nursing team rounds on their patients hourly it is shown to have a relationship with a decrease call light use, falls, pressure ulcers, decrease in patient anxiety and increase in patient satisfaction rates (Ford, 2010). When hourly rounding does not occur on a hospital and patients cannot predict when the nurse will be available for physical and emotional assistance this can lead to patient consequences. When a patient cannot predict when the nurse will be available to assist or discuss can concerns that patient’s has can lead to an increase the patient’s anxiety level (Mitchell, Lavenberg, Trotta, & Umscheid, 2014). When a patient’s anxiety levels rises, the patient will try to compensate with inappropriate coping mechanisms such as, the patient trying to go to the
This systems limits patient involvement creates a delay in patient and nurse visualization. Prior to implementation of bedside shift reporting an evidenced based practice educational sessions will be provided and mandatory for nursing staff to attend (Trossman, 2009, p. 7). Utilizing unit managers and facility educators education stations will be set up in each participating unit. A standardized script for each nurse to utilize during the bedside shift report will be implemented to aid in prioritization, organization and timeliness of report decreasing the amount of information the nurse needs to scribe and allowing the nurse more time to visualize the patient, environment and equipment (Evans 2012, p. 283-284). Verbal and written bedside shift reporting is crucial for patient safety. “Ineffective communication is the most frequently cited cause for sentinel events in the United States and in Australian hospitals 50% of adverse events occur as a result of communication failures between health care professionals.” Utilizing written report information creates accountability and minimizes the loss in important information during the bedside shift report process (Street, 2011 p. 133). To minimize the barriers associated with the change of shift reporting process unit managers need to create a positive environment and reinforce the benefits for the procedural change (Tobiano, et al.,
Clinical alarm systems form a very important component of the overall patient safety since they alert caregivers of potential problems. This goal pertains to development of a systematic, coordinated approach to clinical alarm system management
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
Unfortunately, it is too late for the Garcia family. Their tragedy should not be in vain and the healthcare industry should learn from the aforementioned mistakes. Patients put themselves in our hands for care; they should not die from alarm fatigue. By conducting an RCA and finding solutions that are supported by evidence based practice, patient safety can be accomplished and alarm fatigue can decrease. There is no reason why a sentinel event should happen, due to alarm fatigue, as it is something that can be prevented. As health care clinicians, it is our job to keep the patients safe and keep the hospital’s reputation from degrading.
Although nurses and other health care workers can control only a small percentage of false alarms that lead to alarm fatigue, staff can help reduce the number of these alarms and increase patient safety through the application of the aforementioned evidence-based interventions. As supported by the literature, nurse leader-managers must make addressing alarm fatigue a top priority in their units and hospitals. Alarm fatigue is a serious issue in this age of information and will only become more relevant as complex technology becomes more and more standard in an increasing number of hospitals. Without more research and new developments in alarm algorithms, alarm fatigue will continue to be a significant problem. Because medical device companies are pressured to develop products with extremely high sensitivity to reduce their own liability, this barrier is a difficult one to address (Imhoff, 2009). Despite this momentous obstacle, nurses can still advocate for better alarm management systems and for greater advancement in this area of patient
According to the author, nursing practice needs to stay current with technological advances while keeping its identity as a patient focused profession. Nurses use technology to improve care from a patient?s perspective, both in quality of care and cost. At the same time, nurses must learn to balance technological knowledge with personal skills, thus providing optimum clinical care while maintaining a person-focused relationship with the patient.
Previously, ineffective communication, was recognized as the foremost cause of sentinel events (Doerhoff & Garrison, 2015). Interestingly, the individual human factor, fatigue, leads to ineffective communication (Doerhoff & Garrison, 2015). Fatigue causes delays in attention and memory, confusion, and irritability (Gardner & Dubeck, 2016). All of which negatively affect a nurses ability to communicate with patients, providers, and other nurses. Furthermore, if hospital leaders allow nurses to work excessive hours without a break or increase a nurse’s workload, it can worsen fatigue leading to poor decision making. Poor leadership can lead to the development of fatigue which then results in ineffective communication. The interconnection of human factors, especially fatigue, with the other top root causes of sentinel events, indicates that human factors are indeed the root cause that poses the greatest potential danger to patient
In addition, the charge nurse needs to reinforce the safety check among nurses in regular basis. On the other hand, nurses are spending a great amount of time on charting their assessments outside the patients’ rooms. Knowing that every patient room is equipped with a computer, nurses can complete all their nursing risk assessment at the patient’s bedside in order to provide some supervision to the patients especially clients at high risk for falls and injuries. Furthermore, nurses are great educators. Teaching patients how to use their call bell during admission and have the patient demonstrate back is a big intervention to encourage patients to press the call button when help is needed instead of getting out of bed on their
A 2013 alert issued by the Joint Commission brought alarm fatigue to the forefront of healthcare safety. The investigation prompting the alert cited alarm fatigue as the most frequent contributing factor in 98 alarm-related sentinel events that were reported between January 2009 and June 2012. Of those 98 events, 80 resulted in patient death and 13 resulted in permanent loss of function (Joint Commission,
There are RRTs at each one of these facilities around the clock. At new employee orientations one of the first protocols trained to each employee is how to issue a rapid response. Norton instructs every employee to call “3333” and issue a rapid response if the caller suspects a patient to be showing signs of early deterioration. Norton also informs all members that if the response ends in a false alarm that no penalty be issued and patient safety always comes
Everyday risks present themselves in various workplaces through a variety of situations. Risk managers have been set in place to establish rules and guidelines by which employees are to follow. Any risk manager would agree that programs are set into place to reduce exposure risks, and provide a safe working environment. The elimination of undesirable outcomes in an emergency setting is critical and should not be taken lightly. Medical facility holds the key to important protocols and needs to work closely with risk management in order to instill cooperation.
For years healthcare delivery has been limited to health provider areas such as hospitals, doctors offices, clinics and other facilities offering care. The introduction of mobile technologies in the healthcare field has changed the way health care is practiced and plays a key role in its future. Concerns remain at the forefront of discussions regarding patient privacy and transmission of proprietary data. The introduction of the personal digital assistant and smart phone will revolutionize care in the coming years.
Nursing assessments are to be completed at least once every 12 hours and include each physiological system. Assessments are documented in electronic medical records (EMRs) by charting by exception, or complete documentation of all physiological systems (Rothman, Solinger, Rothman, & Finlay, 2012). According to Weis and Levy (2014), EMRs have led to a series of techniques that are called content importing technology (CIT), which make it possible to import information about patients into the chart and move the information to other sections of the EMR. CIT techniques offer opportunities for efficiency, but they can be misused (Weis & Levy, 2014). Subbe and Welch (2013) defined failure to rescue (FTR) as the lack of the proper response to patients who are deteriorating in the hospital.