Patient Safety Statement and Chosen Cause that will Drive Improvement
Alarm fatigue is one issues that I notice nurses deal with daily. The constant ringing of alarms from call light, ventilators, feeding tubes, iv pumps and cardiac monitor can lead to a stressful day for a nurse. These are a few things that eventually cause nurses to tone out alarms and place patient safety at risk. Mr. John Doe was admitted with Atrial fibrillation with rapid ventricular response (afib with rvr) to a small unit. His alarm had been alarming all day with no relief. During the change of shift when hand off was given the oncoming nurse change the setting on the main cardiac monitor. The following day no one notice that the patient in Afib monitor never alarmed
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to his rate. After placement of a picc line the patient ECG changed, he went into ventricular tachycardia went into cardiac arrest and was coded and he died. This is one of the main reason alarm fatigue is dangerous to patient. Decreasing alarm fatigue is the main focus of this paper. Current Knowledge of the Patient Safety Concern Alarm fatigue is constant problem for ICU and Telemetry Nurses “it is estimated that between 80%-99% of alarms in the clinical area are in actionable alarms (Gross, Dahi, & Nielson)”.
In other words, all alarms require some form of intervention however; due to the high volume and constant noise nurses has develop a tone ear to the alarms. “Premature Ventricular contractions alarms account for more than 40% of all the alarms” (Srinivasa, Mankoo, Kerr).
Due to the increase technology used by nurses so have the noise level on the ICU/telemetry unit. When ten nurses were poll as to why they do not change the parameters to fit the patient need and at the same time stop the alarms from going off, 50% reported that they would need an order from the doctors to change, 10 % stated that they went by what the patient was already placed on the monitor, and the other 15% stated they could not give an answer as to why they did not change it. In truth, most nurses are scare of the repercussion of changing the
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parameters. For three days, I monitor the alarms on the unit for 5 patients to see how long it took the nurse to respond to the alarm. Most nurses paid no mind to the monitor and continue with their task at hand. When asking a nurse why she did not respond to the alarm, she simple said that she wait to see if it continues to alarm. That seems to be the common practices. The alarm is trigger by a parameter that fall short of the goal intended. When the unit is in constant array of alarms from ventilation, tube feeding and iv pumps it can easily be “overlooked or ignored because the important alarms are drowned out by superfluous alarms” ( Sinivasa, Mankoo ,Kerr). and toned out and so a patient safety is at risk. The nonactionable alarm account for 50% of the alarms going off. “It is generally acknowledged that auditory alarms used in healthcare are poorly designed (Phillips, Barnsteiner,)”. The goal of Joint Commission’s National Patient Safety for 2014 is the control of alarms. The main goal will be to increase the response time for alarms that are actionable to 75% by the summer of 2017 to ensure a better outcome for patient. “Numerous risk points contribute to alarm- and monitoring-related adverse events, including alarm fatigue, communication breakdowns, training issues, and equipment failures” (Flowers). Proposed Improvement Plan and Rationale The collaboration of Nurses, Doctors, and Bio-meds to program the Monitor to turn off the Pac and PVC on the monitor on one room for a study to see if the alarm trigger is decreases.
According to Joint commission “a recent Globe investigation found that, from January 2005 to June 2010, 216 hospital patient deaths nationwide were linked to issues with patient monitor alarms. In many cases, medical staff failed to notice the alarm or take immediate action to help a patient in distress.” When the post ox is not in use to turn off the parameter on the monitor. Next step would be to place the monitor on standby when patient is off the unit to prevent the constant alarming. Retraining of the nurse to the monitor to help trouble shot can benefit the patient as well as the nurse to help them to be more proficient in their task. Small changes can lead to a better outcome for patient safety. The pilot will take place in ICU with all nurse educated on the process along with the doctors. Two monitor will be as to voluntary to monitor the alarms and the response time. Data will be collected for two weeks and reevaluated to ensure that Patient safety is first and foremost maintain. All information would be shared with nurses, management, Doctors and
Bi0-Med. Proposed Improvement Intervention This small act can decrease the alarms from going off. Once a patient is discharge from the monitor and a new patient placed in the room the monitor automatically goes back to factory default. Most nurses are not aware of this and will post a parameter for a heart rate 20- 200. However, this is not the main reason for the alarms going off but the reason for sentinel event to occur. The alarms are set to notified staff of change but as reported the constant alarm can cause nurses to ignore the noise. The most common alarms are pvc ,pac this account for the 90% of the nonaction required. To turn off the PVC and PAC on the monitor could help decrease the alarms fatigue. Studies have shown that no actinal alarms is the main cause of alarm fatigue. Proposed Implementation Plan The plan will be monitor by two nurses and 1 doctor for the first two weeks. The doctor will be able to monitor the labs to make sure that the patient electrolytes are within acceptable range to eliminate pvc and pac on the monitor. The nurses will customize the monitor to fit the patient hear rate and blood pressure and adjust accord to the patient rate. The number will increase by x5 every third week and reevaluate every two week. With each increase with patient monitor change the nurses should feel more comfortable and the response time for the alarms should improve by 50% If all goes well the plan will be for safety goal with Joint commission and move from Icu to the telemetry units within one year of implications. Proposed Measures to Evaluate Effectiveness Plans to evaluate the effectiveness require all the staff to take notice and to work together as a unit. To hold staff accountable for all patient and not just their patient. To check the monitor to make sure that the setting is adequate for patient safety. To do a survey to see what else staff think would improve the noise reduction on the alarm. To include the patient on feedback on the alarms and what their concerns are. These are a few thing that could help with the success of the project. j
Patients expect instant response to call lights due to today’s technological advancements. This can negatively impact nurse stress and cause contempt toward the patient. However, the expectation to respond promptly improves safety and encourages frequent rounding. Also, aiming for high patient satisfaction scores on the HCAHPS/Press Ganey by fulfilling patient requests can overshadow safe, efficient, and necessary healthcare. Although patient satisfaction is important, ultimately, the patient’s health takes precedence over satisfying patient and family requests, especially when those requests are unnecessary, harmful, or take away from the plan of care (Junewicz & Youngner, 2015). The HCAHPS/Press Ganey survey focuses on the patient’s perception of care. The problem with this aspect of the survey is that the first and foremost goal of nurses should not be to increase a patient’s score based on perception. According to an article in Health Facilities Management, the nurse’s top priority is to provide the safest, most quality care possible for patients with the resources they are given (Hurst, 2013). Once this has been accomplished, the nurse can then help the patient realize that the most
With patient safety always being the number one priority FTR is the worst case scenario for the hospitalized patient. In an article titled “Failure to Rescue: The Nurse’s Impact” from the Medsurg Nursing Journal author Garvey explains ways FTR can occur “including organizational failure, provider lack of knowledge and failure to realize clinical injury, lack of supervision, and failure to get advice.” Nurses are problem solvers by nature, they heal the sick and help save lives. FTR is a tragic experience for everyone involved. The recent surge in this happening across the country has given FTR cases widespread media coverage. Hospitals are trying to figure out what the root cause is and how they can be prevented. Fortunately, with the advancement of technology and extensive research many hospitals have developed action plans and procedures to help prevent the early warning signs from being
Human factors are derived from construction and adapted to a system of development in health care by carefully examining the relationship between people, environment, and technology. The consideration of human factors acknowledges the capability or inability to perform a precise task while executing multiple functions at once. Human factors provide an organized method to prevent errors and create exceptional efficiency. Careful attention must be exercised in all levels of care such as the physical, social, and external environment. It is also vital to carefully consider the type of work completed and the quality of performance. Applying human factors to the structure of healthcare can help reduce risks and improve outcomes for patients. This includes physical, behavioral, and cognitive performance which is important to a successful health care system that can prevent errors. A well-designed health care system can anticipate errors before they occur and not after the mistake has been committed. A culture of safety in nursing demands strong leadership that pays attention to variations in workloads, preventing interruptions at work, promotes communication and courtesy for everyone involved. Implementing a structure of human factors will guide research and provide a better understanding of a nurse’s complicated work environment. Nurses today are face challenges that affect patient safety such as heavy workloads, distractions, multiple tasks, and inadequate staffing. Poor communication and failure to comply with proper protocols can also adversely affect patient safety. Understanding human factors can help nurses prevent errors and improve quality of care. In order to standardize care the crew resource management program was
A considerable amount of literature has been published on the impact of working hours (8 vs. 12 hour shifts) on fatigue among the nurses. These studies revealed that twelve-hour shifts increase the risk of fatigue, reduce the level of alertness and performance, and therefore reduce the safety aspect compared to eight-hour shifts (Mitchell and Williamson, 1997; Dorrian et al., 2006; Dembe et al., 2009; Tasto et al., 1978). Mills et al. (1982) found that the risk of fatigues and performance errors are associated with the 12-hour shifts. Beside this, Jostone et al. (2002) revealed that nurses who are working for long hours are providing hasty performance with increased possibility of errors.
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.
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...
In their research study they tested the use of “a patient-monitoring system designed to optimize patient-turning practices” (Pickham et al. 2016), this system involves sensors being attached to patients and allows the nurses to determine “the patient 's current position and time-to-next-turn” (Pickham et al. 2016). As a result of this evidence based practice, these researchers were able to use their clinical expertise to gather patient data in order to improve nursing practice, as a result “After implementation of the system, compliance and patient turning was reported to have increased significantly from 64 to 98 %” (Pickham et al. 2016), therefore this is definitely something that could assist all nurses in helping the to perform their jobs more proficiently. However since this kind of monitoring is not currently used in all medical facilities, the importance of frequent re-positioning of patients is something I will remember and implement
It’s hard to leave a loved one in a hospital bed when night falls. Family members leave with a sense of responsibility, guilt, and sadness. They leave relying on the nurse to watch and care for their sick family member. Therefore, it is heart breaking to find out the next morning your loved one has suffered great brain damage due to nurses failing to check on alarm sounds. Now, the family is put on the spot to continue life support or disconnect their family member. One can only imagine what went wrong; up to the minute that you left the hospital, your loved one was doing fine. You are relying on the health care providers to take care of your loved one, just as you would, while you are gone. Staff made an error by ignoring the alarms sounds, warning them that the patient was deteriorating, and costing the patient’s family a great deal of pain. Jenifer Garcia’s life shattered when this exact event happened to her husband in July, 2010 (Kowalczyk, 2011). She left her husband Friday night, alive, and returned the next morning to find out he was brain dead. Advancements in technology are used to decrease and catch medical errors made by health care providers that can harm or kill patients, but alarm fatigue has proven that even technology cannot fully protect a patient from nursing errors, thus taking the lives of patients.
The term “failure to rescue” refers to a clinical scenario where hospital doctors, nurses, or caregivers fail to recognize symptoms. Responders do not respond adequately to clinical signs that would prevent harm (Morse, 2008, p.2). Dr. Jeffery H. Silber, Director of the Center for Health Outcomes and Policy Research, first coined the term “failure to rescue” in the 1990’s. He characterized the matrix of institutional and individual errors that contribute to patient deaths as “failure to rescue” (Aleccia, 2008). Since 1990, it has been well documented patients usually exhibit signs and symptoms of impending cardiac or respiratory arrest 6-8 hours before an arrest (Schein, Hazday, Pena, Ruben, & Spring, 1990). Buist, Bernard, Nguyen, Moore, and Anderson’s (2004) research reported similar findings. They found patients had documented clinically abnormal signs and symptom prior to arrest (Buist, et al., 2004). When certain abnormal signs and symptoms are identified early, critical bedside consultat...
The staff will now have to rely heavily on technology to monitor delicate vital signs and feeding schedules as well as charting assessments. The large panoramic view of a room has been replaced with walls and a nurse watching a com...
“This literature review explores the effect that nurse staffing patterns have on the frequency of medical errors, fatigue, and nurse burnout (Garrett, 2008, p.1191)”. A concept that is relevant to this study would include nurse sensitive concepts. Houser stated that nurse sensitive concepts include but are not limited to burnout, medication errors as well as patient falls (Houser, 2015). All these concepts are relevant in this one article which discusses studies that have been done to provide evidence based research. “Variables included total staff member work hours and nurse-sensitive outcome rates for CLIs, pressure ulcers, medication errors, falls and restraint application duration rates (ie, duration for use of mechanical restraints)(Garrett, 2008, p.1197).” The technique that was used in this research was the quantitative method. The text book defines quantitative research as “a traditional approach to research in which variables are identified and measured in a reliable and valid way” (Houser, 2015). This study that was conducted identified variables as stated above as well as collected data from diverse units of hospitals to analyze separately to measure the outcomes. The participants of this study included ninety five patient care units from ten adult acute care hospitals for this sample. The instrument used by the researcher was from an observational form that
Imagine, you are a nurse in the middle of your shift when all of the sudden the alarm system sounds and over the intercom you hear “Doctor Quick Response Team Cardiac Unit”. You begin to feel flush, your heart is pounding and you become nervous, the questions start racing through your head “am I ready to respond, what am I going to do?” This reaction is completely normal, in fact in today’s health care setting the needs of health management services are increasing and more and more health care professionals are feeling the stress especially during medical emergencies. Therefore, it is important for hospitals and health care settings to have a policy in place to hold mock clinical simulations, for in times of emergency to allow for health care provider to practice and prepare to respond to medical emergencies in a rapid and organized fashion.
With the introduction of the age of computers, the nursing profession has seen a transition from the manual to automated methods of record keeping and even patient management. With the introduction of new technology even in monitor systems within the hospitals, nurses are compelled to increase their scope of learning in order to cope with the changes. Intensive care unit equipment are highly sophisticated which only increases the pressure on the nurse as a learner (Urquhart, Currell, Grant & Hardiker). This explicitly shows that nursing is a
Lippincott , Williams, & Wilkins, (2012). Sentinel event alert spotlights nurse fatigue. Clinical Rounds, 42(3), 27-29. doi: 10.1097/01.NURSE.0000411416.14033.f5
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...