Alarm Fatigue a Sentinel Event
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.
Sentinel Event
A sentinel event is an unforeseen incident that results in death, physical harm, or psychological injury of a patient not related to the patient’s illness (The Joint Comission, 2011). Sentinel events include, but are not limited to, surgery on the wrong patient or body part, rape, suicide, instruments left inside patient, and/or medications errors. All sentinel even...
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...decrease as time goes on, because the money used for the study, new monitors will not be included any more. In the end, the budget will be paid off in time due to decreased sentinel events and change in time shifts.
Conclusion
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.
Nurses are central to patient care and patient safety in hospitals. Their ability to speak up and be heard greatly impacts their own work satisfaction and patient outcomes. Open communication should have been encouraged within the healthcare team caring for Tyrell. Open communication cultures lead to better patient care, improved outcomes, and better staff satisfaction (Okuyama, 2014). Promoting autonomy for all members of the healthcare team, including the patient and his parents, may have caused the outcome to have been completely different. A focus on what is best for the patient rather than on risks clinicians may face when speaking up about potential patient harm is needed to achieve safe care in everyday clinical practice (Okuyama,
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
Nobody is perfect. We all make mistakes. Some of the best lessons in life are learned from making a mistake. But in the healthcare world making mistakes means losing lives. This has started to happen so frequently there has been a term coined – Failure to Rescue or FTR. Failure to rescue is a situation in which a patient was starting to deteriorate and it wasn’t noticed or it wasn’t properly addressed and the patient dies. The idea is that doctors or nurses could’ve had the opportunity to save the life of the patient but because of a variety of reasons, didn’t. This paper discusses the concept of FTR, describes ways to prevent it from happening; especially in relation to strokes or cerebrovascular accidents, and discusses the nursing implications involved in all of these factors.
Disclosure of sentinel and adverse events has been an ongoing issue in healthcare. According to King, the Institute of Medicine reported that 44,000 to 98,000 people die every year from medical errors (King, 2009), According to the National Center for Ethics in Health Care, a sentinel event is a unanticipated death or outcome which is not related to the patient's underlying illness (National Center for Ethics in Healthcare, 2003). Josie's Story by Sorrel King is based on a true story which depicts a heartbreaking yet inspiring story of a young child whose live was taken due to a sentinel event. According to King, Josie died unexpectedly due to a sentinel event. A sentinel event is an event in which there has been an unanticipated outcome resulting in death or further complications. The healthcare team's duty was to investigate Josie's case, and come up with a resolution to avoid it from happening in the future (King, 2009).
Hospitalized patients are often hooked up to monitoring devices such as heart monitors, which monitor the electric activity of the heart, or connected to a physiological monitor so their vital signs are constantly being measured. These monitors are intended to continuously assess the patients’ status, and alarm if the patients’ status drops below what is considered normal. The increased use of monitoring devices has created a new phenomenon known as alarm fatigue. According to the ECRI institute (2011), “alarm fatigue occurs when the sheer number of alarms overwhelms staff and they become desensitized to the alarms resulting in delayed alarm response and missed alarms-often resulting in patient harm or even death.” Alarm fatigue has become a major problem within the nursing community and has already had a negative impact on patient safety. Due to the adverse effects alarm fatigue is having on quality patient care, there has been a call to action to find solutions that may deter alarm fatigue. Evidence-based practices involving quality improvement initiatives have been put into effect. The problem has also gained national attention from such institutions as the Food and Drug Administration (FDA) and The Joint Commission (TJC).
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).
JB McKenzie, et al. "STRATEGIES USED BY CRITICAL CARE NURSES TO IDENTIFY, INTERRUPT, AND CORRECT MEDICAL ERRORS." American Journal of Critical Care 19.6 (2010): 500-509. CINAHL Plus with Full Text. EBSCO. Web. 7 Mar. 2011.
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.
In saying 1.5 million Americans have witnessed hospital errors in the care of the medical center or even 40,000-100,000 deaths is a ridiculous amount of faults. Errors should be minimized, especially when dealing with people’s lives. The number of deaths is so high hospitals should take notice and really pinpoint where their facility is miscalculating and create in-service training to all employees and not just the ones that are making the errors but all employees. This will decrease the chances of errors made in the hospital. With continuous training every month there can be a huge change in the number of mistakes. The fact that these inaccuracies are even causing deaths really highlight the importance of the need for a change. Families
The rate of errors and situations are seen as chances for improvement. A great degree of preventable adversative events and medical faults happen. They cause injury to patients and their loved ones. Events are possibly able to occur in all types of settings. Innovations and strategies have been created to identify hazards to progress patient and staff safety. Nurses are dominant to providing an atmosphere and values of safety. As an outcome, nurses are becoming safety leaders in the healthcare environment(Utrich&Kear,
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
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
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).
Bed alarms can be used to alert staff when a non-ambulatory patient is getting out of bed. Always keeping the patient’s call light within reach is a necessity so they may call for help if needed. If there is family visiting and they feel comfortable keeping an eye on the patient then there is no need for any type of restraint if safety is not compromised. If restraints are to be used, there are guidelines on how often they must be checked to assess for circulation and pressure sores. Careful documentation must be kept if restraints are used and there must be a doctor’s order. There should be no long term complications if proper protocol is followed. The point of this being if staff can see negative data and how it impacts them, they can work harder to prevent those situations from occurring. Preventing complications will decrease patient’s hospital stays, decrease patient’s risk of developing long term issues related to hospital stay, and improve patient
Sleep is a very important factor in the human function. Our body and brain is able to reset itself and rejuvenate while we sleep. When we do not get the required amount of sleep, we start to feel lethargic and foggy minded, because our mind and body wasn’t able to replenish itself. Sleep is imperative that an insignificant rest deficiency or lack of sleep can affect our ability to remember things; decisions and can affect our temperament. Chronic sleep deficiency can get the body to feel agitated and it could lead to serious health problems such as, heart problems, stress, acne, and obesity.