Alarm Management Quality & Risk 2014

Objectives Review National Patient Safety Goal around Alarm Management What causes alarm fatigue and what is the impact? Identify false-alarms and the causes. Review Patient Safety impact from alarm fatigue Identify strategies for improving patient safety around alarm management.

National Patient Safety Goal - Alarm Fatigue Goal 6: Use Alarms Safely. NPSG.06.01.01 Make improvements to ensure that alarms on medical equipment are heard and responded to in a timely manner. A L R M S lways physically enter the room during an alarm. ook at the patient! larms should be audible over competing noises. eason! Evaluate the reason for the alarm. ake sure to check the alarm before and during a surgical procedure. top turn-off capabilities; do NOT deactivate.

How SERIOUS is Alarm Fatigue? Since 2005, more than 216 patient deaths have been directly attributed to alarm fatigue. 2007 77-year old was admitted to a telemetry unit. Alarms for “low battery” went unanswered. Patient had cardiac arrest and died. January 2010 89-year-old patient was in the ICU. Bedside alarm was turned off. Alarmed sounded at the central nurses’ station. Nurses on duty said they did not hear the alarm or see the digital display. August 2010 60-year-old man was admitted to the ICU after a tree fell on him, resulting in facial trauma and head injury. He was agitated and received lorazepam 5 mg IV push. The order was for “small doses up to 5 mg.” An hour later, tachycardia and low oxygen saturation (SpO2) alarms went unanswered for an hour. Respiratory arrest was called. Patient was resuscitated and placed on a ventilator. CT scan showed an anoxic injury of the brain. Family withdrew the patient from life support after several days.

Frequent and Persistent Problem Joint Commission reports 98 alarm-related events between 1/2019 and 6/2012. 80 of those resulted in death 13 resulted in permanent loss of function 5 resulted in unexpected additional care or extended stay 94 occurred in the hospital setting. Common injuries or deaths related to alarms included: Falls Delays in treatment Ventilator use Medication errors

Major Contributing Factors Absent or inadequate alarm system Improper Alarm settings Alarm signals not audible in all areas Alarm signals inappropriately turned off Alarm Fatigue Alarm settings that are not customized to the individual patient or patient population. Inadequate training on proper use and functioning of the equipment Inadequate staffing to support or respond to alarm signals Equipment malfunctions and failures NOTE: Alarm Fatigue was the most common contributing factor

What’s the problem? How does Alarm Fatigue happen? It occurs when staff members are exposed to an excessive number of alarms. Staff become desensitized to alarms. The result is in sensory overload: Staff become frustrated Alarm response is delayed due to other priorities Alarms get missed. Patients/families try to help by turning off alarms before a nurse responds. Patient safety becomes a risk.

What’s the Facts, Jack? Some Alarms are just nuisance alarms!! May interfere with patient care. Are perceived as annoying. Are not the result of adverse patient conditions. Distract from other tasks or focus. Some alarms are just False Alarms! Alarms are detected by a medical device. Indicate the need for a response even when it’s a false alarm. Alarms can be triggered without a true patient event. False alarms are usually the result of: Parameters not set to actionable levels Too tight thresholds

The Fact of the Matter is……… Technology It’s a Natural part of the environment Physiologic monitoring It’s the Standard of care and practice Devices They are only as reliable as the clinicians who use them Alarms Are Inherent in the clinical environment Are Intended to alert clinicians to deviations from a predetermined “normal” status Do compromise patient safety if ignored

Staff Perception……. Alarms are a necessary evil. Staff may not view alarm fatigue as a problem or real threat to patient safety. Alarms may be used as a stop-gap measure for a lack of monitoring. Use of alarms is a possible means to eliminate and/or replace staff or clinicians with technology.

Recommended Approach to Alarm Fatigue The best way to prevent alarm fatigue is through proactive alarm management. We MUST: Decide who can make changes to the alarm parameters. Tailor alarm parameters to the: Individual patient Specific patient population Evaluate whether the: Alarms are audible and visually displayed. Critical alarm sound is distinguishable over unit noises and other alarms.

Recommended Approach to Alarm Fatigue (continued) Decrease false-positive alarms. Make changes to help staff decipher priority alarms. Troubleshoot false alarms when they occur. Avoid ignoring them. Avoid alarm work-arounds.

Recommended Approach (continued) Do not overuse physiologic monitoring. Avoid keeping the patient on telemetry monitoring longer than necessary. Never turn off an alarm. Consider silencing while you troubleshoot. Assess the reason for the alarm. Intervene as appropriate.

Be Sharp… Be Alert… Be Focused… Alarm Management It must be part of our: Culture Staff responsibilities Technology Policies and procedures Processes It must support: Prompt and efficacious alarm verification Notification Response Documentation

Alarm Management Strategies Communicate to patients and visitors that prompt responses to alarms are a top priority in keeping patients safe. Make all alarms actionable: Staff should be only alerted to clinically significant alarms that require response Default alarm parameters and ensuring parameters are appropriate for the individual patient will be analyzed. On-going education and validation of staff competency on customizing alarm parameters

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