Reducing Alarm Fatigue to Improve Patient Safety
Ashley E. Mullins
Baker University School of Nursing
Reducing Alarm Fatigue to Improve Patient Safety The cacophonous, resounding clang of the alarm can be the gatekeeper between life and death for a patient. Alarms bring providers to the rescue and allow for an array of immediate interventions, from preventing a disoriented patient from falling to signaling impending medical crisis or malfunction of vital assistive equipment. Much of the time, however, these alarms are either clinically insignificant or inappropriately triggered and thus deemed “nuisance alarms.”
It is estimated that, of the hundreds of alarms critical care nurses are exposed to each day, 85-99% hold no significance for
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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, …show more content…
An observational study conducted by Drew et al. (2014) reflects these findings. The study found that 88.8% of annotated arrhythmia alarms were false positives. This is largely attributed to narrow or inappropriate device parameters. Critical alarms that must be manually silenced by a clinician were routinely set off by benign activities such as a patient brushing his or her teeth, creating an incessant burden for caregivers. The study that, most commonly, monitoring devices were not adjusted to the individual patient. Hospital default settings were kept as set parameters regardless of the patient’s baseline, size or condition, routinely resulting in unnecessary alarms and fostering an environment in which a critical event might be overlooked or drowned out due to sensory
In September 2015, PVHMC established the Hospital Gold Alert policy with the purpose of establishing a quick response notification process for patients presenting with two or more indicators of Systemic Inflammatory Response Syndrome (SIRS). According to the Sepsis policy indicators for SIRS include: 1) heart rate great than 90 beats/minute, 2) Respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mmHg, 3) WBC great than 12,000 cells/mm3, less than 4,000 cells/mm3 OR bands greater than 10%, and 4) Temperature greater than 38oC/100.9oF OR less than 36oC/96.8oF. It is also noted in the policy that either a nurse or a physician can initiate a “Gold Alert.” Upon identification of two or more indicators, the “Gold Alert” is announced via overhead speaker and includes responder location.
An audit of patient records completed in 2005, revealed a low incidence of respiratory rate recording. An initial audit completed revealed that only 7% of 341 patients had a respiratory rate recording (Butler-Williams 2005). Due to this worrying outcome, the priority was to implement appropriate training to raise respiratory rate significance. Due to the audit being completed hospital wide and with no prior warning, it is an accurate indicator of an overall attitude of practice towards the recording of respiratory rate. Various studies have been conducted in order to gain an understanding as to why this precious sign is so often ignored. Jacqueline Hogan explored the paucity of patient monitoring on acute wards, completing qualitative research using focus groups in 2004. Four major themes were identified, firstly the issue of the nursing workload. Many participants acknowledged the expansion of the nurse’s role and with this added responsibility, the need for delegation of activities such as patient observations. Observations are often delegated to junior staff members such as healthcare assistants and student nurses. Although many nurses admitted to delegating this vital activity, 73% of nurses did not consider healthcare assistants possessed the required knowledge to interpret observational results. With this lack of knowledge comes the absence of appreciation for the completion of such vital signs, and
In intensive care units it recorded the impact I could get to have a high incidence of sentinel events. The incidence may be underestimated because the data and results obtained are not the totality of the events by the known missing or insufficient information. Knowledge of the possibility of the occurrence of sentinel events and consequences that occur after the occurrence of this during the care provided by nurses in the ICU, constitutes an essential tool for providing your care with higher quality and more certainty.
While nurses are working on a floor there are many different machines that have alarms such as IV pumps, ventilator machines, ECG’s, vital machines, call lights, and pagers. New nurses have shown a lack of response efforts to combat these alarms from a proposed desensitization and sensory overload of the alarm noise (Cvach, 2012). This is a patient safety concern due to what the alarms purpose is which in turn leads to varying amounts of potentially severe consqeunces if not answered promptly. Between 2009 and 2012 the joint commission stated that there were 80 patient deaths, 13 permanent losses of function, and 5 events that led to extended hospital stays (Horkan, 2014). It is important for nurses to recognize alarm fatigue and find interventions to help keep patients from being injured.
The nursing discipline embodies a whole range of skills and abilities that are aimed at maximizing one’s wellness by minimizing harm. As one of the most trusted professions, we literally are some’s last hope and last chance to thrive in life; however, in some cases we may be the last person they see on earth. Many individuals dream of slipping away in a peaceful death, but many others leave this world abruptly at unexpected times. I feel that is a crucial part to pay attention to individuals during their most critical and even for some their last moments and that is why I have peaked an interest in the critical care field. It is hard to care for someone who many others have given up on and how critical care nurses go above and beyond the call
The nursing profession is a profession where people put their trust in you to provide care that is not only effective, ethical, and moral, but safe. Not all health situations are simple or by the book. Not all hospitals have the same nurse-patient ratios, equipment, supplies, or support available, but all nurses have “the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm” (ANA, 2009). When arriving at work for a shift, nurses must ensure that the assignment is safe for not only the patients, but also for themselves. There are times when this is not the situation. In these cases, the nurse has the right to invoke Safe Harbor, because according the ANA, nurses also “have the professional right to accept, reject or object in writing to any patient assignment that puts patient or themselves at serious risk for harm” (ANA, 2009).
First to identify factors that contribute to a patient falling. Many patients that are appear to be at a high fall risk and appropriate for the use of a bed alarm are patients who are cognitively impaired, who have an unsteady gait, patients that have many wires or lines and need the assistance of a nurse or patient care assistant (PCA) to ambulate and patients who are a threat to violence. Other factors that many contribute to falls include the bed or chair exit alarm not being turned on, the alarm not being properly set up, family members turning off the bed alarm or trying to assist the patient to get out of bed, alarm malfunction, or infrequent checks on the patient to ensure they are comfortable a...
After review of the timeline of the events surrounding Mr. B, there are several causative factors that led to this sentinel event. These are inappropriate staffing, inability to identify trends of deterioration, policy for conscious sedation was not followed, inadequate observation and monitoring, failure to respond to alarms, inadequate home medication evaluation, medication dosing, appropriate medication administration times, and failure to start cardiopulmonary resuscitation in a timely manner.
Patients Safety is the most crucial about healthcare sector around the world. It is defined as ‘the prevention of patients harm’ (Kohn et al. 2000). Even thou patient safety is shared among organization members, Nurses play a key role, as they are liable for direct and continuous patients care. Nurses should be capable of recognizing the risk of patients and address it to the other multi disciplinary on time.
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
Each year this panel of experts put a microscope on patient safety across the board. They decide where upmost attention needs to be paid. Sometimes items leave the list because there are been strides take to improve in that area and sometimes it continues to stay on the list because they believe the relevance and importance is growing. Healthcare is evolving b...
Lippincott , Williams, & Wilkins, (2012). Sentinel event alert spotlights nurse fatigue. Clinical Rounds, 42(3), 27-29. doi: 10.1097/01.NURSE.0000411416.14033.f5
In the best of days, we see minimal action, but in the craziest of times many things seem to compound and defeat our efforts. This paper is being presented to review the needs of updating our rapid response guidelines and rapid response teams. Being a front line nurse places ourselves in the most peculiar situations. We, as nurses, are the ones who notice and document changes in patient conditions. It is our keen sense of subtle changes that can enact and illicit responses from areas of higher levels of care. Understanding the purpose of initiating a rapid response creates a sense of reassurance in that there is always someone able and willing to help in declining circumstances.
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
Why is the system a better approach?. This is because, it gives the people involved the full peace of mind needed for them to prolong. The first alert medical alert systems, happens to be like a first aid that is given to a patient. They are mentally, affecting their recipients positively; when they are perfectly introduced in the lives of their subsets their r...