Alarm Fatigue, Patient Safety

National Coalition for Alarm Management Safety: Working to Improve Alarm Management

The Physician-Patient Alliance for Health & Safety (PPAHS) is pleased to announce its participation and engagement with the National Coalition for Alarm Management Safety to improve the practice of managing alarms.

On April 25 and 26, 2014, AAMI Foundation’s Healthcare Technology Safety Institute brought key stakeholders to meet and discuss what can be done to meet The Joint Commission’s National Patient Safety Goal to reduce alarm fatigue and improve alarm management. Stakeholders included hospitals, manufacturers, regulators, and health and safety organizations.

According to The Joint Commission Sentinel Event Alert #50, “Medical device alarm safety in hospitals”, an estimated 85 percent to 99 percent of alarm signals do not require clinical intervention. Because of the number of “non-actionable” alerts and interruptions, clinicians may increasingly experience “alarm fatigue.”

A 2013 survey conducted by PPAHS found that nine out of ten hospitals believe addressing alarm fatigue would increase the use of patient monitoring devices that prevent adverse events, such as brain injury and death.

Maureen Carr (Director, Standards and Survey Methods for The Joint Commission) discussed the implementation of the national patient safety goal to improve alarm management. She indicated that these goals are being implemented in phases:

  • Increasing awareness of alarm management
  • Increase in processes need to be put in place to define ”best practices” for alarm management and safety
  • Development of an Alarm Management Program by the institution that is evident in clinical practice

Maria Cvach, DNP, RN, CCRN (Assistant Director of Nursing, Clinical Standards, The Johns Hopkins Hospital) discussed gaps in knowledge of alarm management, including:

  • Lack of actionable intelligence from alarm signals makes it impossible for nurses to effectively triage their multitasking among multiple patients
  • Lack of understanding of the best types of alarm signals to elicit an action response
  • Lack of knowledge reading who should be monitored and for how long? No consensus agreement to date. What is the effect on outcomes? Should we monitor everyone with Smart alarms?
  • Lack of understanding regarding the best secondary alarm notifications. Are there better outcomes? How should they be defined?
  • Gaps in education are significant, as well as training, credentialing clinicians and determining the right competency level that clinicians should possess when working with continuous monitoring and alarm signals
  • Gaps in defining customization and individualizing patients’ specific alarm parameters
  • Gaps in knowledge of the MD who should know the alarm parameters not just to write the order but to identify what the patient ‘s condition actually warrants

Commenting on the meeting, Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant for the Physician-Patient Alliance for Health & Safety) said, “There was true evidence of commitment and collaboration exhibited by all presenters and participants. More importantly, the National Coalition for Alarm Management Safety will be action-oriented. Hospitals should expect to see guidance and recommendations from the Coalition that will help improve alarm management and increase patient safety.”

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