ALARM FATIGUE in Nursing

ALARM FATIGUE in Nursing

University

Informatics

Why is this important to me?

I am completely numb to most alarms after working in acute care medical surgical. It is scary! I would like to understand more about what can be done since technology will only increase.

What is Alarm Fatigue?

Defined as a Desensitized response to medical alert equipment and technologies due to the frequency

Sensory Overload

Too many phones, pagers and overhead announcements

Missed critical events

Patient safety concerns

Over stimulated staff

Outline

Define Alarm Fatigue

How Alarm Fatigue effects Healthcare

Share the Evidenced Based Data

Explore the Adverse Events

Discover a solution

What are the challenges and benefits

Can a solution be implemented?

Potential References

Citing reports of alarm-related deaths, the Joint Commission issues a sentinel event alert for hospitals to improve medical device alarm safety.

ECRI Institute. Strategies to improve monitor alarm safety.

Alarm fatigue sets off bells. Modern Healthcare

Alarm fatigue a top patient safety hazard. Canadian Medical Association Journal

Over-monitoring and alarm fatigue: For whom do the bells toll? Heart and Lung.

There are so many good sources!!!

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Why are these Relevant?

These sources are directly relevant to why alarm fatigue is a problem that is only getting worse.

How and why it effects healthcare.

Joint Commission reporting of such incidents that have been directly related to alarm fatigue.

How to change the course of alarm fatigue.

Evidence based reporting and studies for reference support.

What is Alarm Fatigue?

Alarm Fatigue is care givers desensitized do to overwhelming amounts of alarms.

The many “beeps, chimes and bells” are the reason for delayed care and even death.

A 12 day study at John Hopkins determined over 350 alarms per bed.

Over 80% are false alarms.

No standardization of alarm technology

The more false alarms the less likely someone responds.

(Jones, 2014)

Where do We begin?

Review the Joint Commission Reports

Speak to Safety Experts in Other Fields

Create a Culture of Safety

Leadership Buy In

Staff Buy In

Redefine the Framework

Trust, Report and Improve- Concepts

Have accountability for safety protocols

(Chassin & Loeb, 2013)

Joint Commission Reports -566 Alarm Related Deaths Between 1/2005-6/2010 -Most Often Reported in ER -85-95% Alarms are false -The Many False alarms desensitize Staff (Ed Manag., 2013)

Summary The amounts of research and data available for alarm fatigue is overwhelming. The data supports a overhaul of the technology systems to become integrated with All of the vital sign alarms. Also to have standards in place for baseline alarm settings. Alarms should also be in reference to baseline health status of patient to prevent false alarms. I still have a lot of work to complete and will be ready to present next week!

Annotated Bibliography

Citing reports of alarm related deaths, the Joint Commission issues a sentinel event alert for hospital to improve medical device alarm safety. ED Manag. 2013;26(6)

This article from ED Manag, which was accessed from PUBMED is a evidence based article that depicts the role of new alarm technologies that are overwhelming to healthcare providers. The Joint Commission has documented the amount of deaths related to these such alarms. This evidence will prove that alarm fatigue causes sentinel events.

Chassin, M. R., & Loeb, J. M. (2013). High‐reliability health care: getting there from here. The Milbank Quarterly, 91(3), 459-490.

The Milbank Quarterly article on how to improve healthcare safety and reliability. It explains how other organizations for example: the airline industry, maintain safe conditions with minimal adverse events. By examining the processes of other industries can perhaps provide insight on managing errors in healthcare. Within such industries there are common factors influencing such gains: leadership, compaines safety culture and effective process tools.

Jones K. Alarm fatigue a top patient safety hazard. CMAJ. 2014;186(3):178. doi: 10.1503/cmaj.109-4696.

CMAJ address that alarm fatigue desensitizes health care professionals and are the leading cause of technology hazards. Deciphering through which of the alarms are actually emergencies are the issue at hand. 80% of alarms are reported as false. Different manufactures use multiple different alarms. There is no distinguishing between sounds and this can lead to ignoring and ultimately alarm fatigue.

McKinney M. Alarm fatigue sets off bells; Mass. incident highlights need for protocols check. ModernHealthcare.2010;40(15):14.www.modernhealthcare.com/article/20100412/MAGAZINE/100409955. Accessed August 2018

Modern healthcare a leader in healthcare news and research reported on a hospital in Boston that had a tragedy with a cardiac patient due to desensitation of cardiac alarms. The alarm had been turned to the OFF setting and for twenty minutes the patients heart rate dropped to ultimately was unable to be resuscitated. The horrible tragedy has brought about good because now the hospital is applying the proper protocols for alarms to be used in best practices for patient safety.

To be continued, edited and new sources added.

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