Alarm Fatigue, Patient Monitoring, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Feb 13, 2015)

We hope there are no superstitious people reading on this Friday the 13th.

Let’s get to it. Must Reads from the past week.

New Stroke VTE Safety Recommendations Prevent Blood Clots In Stroke Patients

Earlier this week, PPAHS announced the release of safety recommendations targeting the prevention of venous thromboembolism (VTE) in stroke patients.

Stroke is a leading cause of death and disability in the U.S., with 800,000 cases occurring each year.

Download the Stroke VTE Safety Recommendations here.

Four Reasons to Expand Capnography

Advance Healthcare Network for Respiratory Care & Sleep Medicine published an article outlining why health systems should expand the use of capnography.

  1. Enhancing patient safety
  2. Newer guidelines and checklists to monitor patients
  3. Improved outcomes
  4. Improved consistency of care.

Citing experts like Dr. Bhavini Kodali, Dr. Frank Overdyk (who sits on the PPAHS board of advisors)—and referencing the PPAHS PCA Safety Checklist—the article is a good summary of why capnography use should be expanded outside the OR.

Health Illiteracy a Root Cause of Medical Error

In 2004, The Institute of Medicine (IOM) released a report, saying that that 90 million people in America have difficulty understanding and using health information.

On a personal blog, Thomas Sharon, RN, MPH, recently shared his perspective on patients who lacked basic health literacy after encountering thousands of patients in the home environment over two decades. It is always good to get perspectives from the field, so we thought we would highlight this blog article.

Both the IOM report brief and Mr. Sharon’s article may be worth reading.

Patient Satisfaction Scores Not Affected by Amount of Opioids Given in Emergency Room

Pain Medicine News reports that researchers at two New England hospitals performed a retrospective analysis of medical records and completed surveys of nearly 5,000 patients seen in the ER department.

The researchers asked whether the amount of opioids administered in the ER were associated with Press Ganey scores, a common tool to measure patient satisfaction, according to the authors. The answer, they found: no.

According to Chris Pasero, pain management educator and clinical consultant:

“What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.”

The new research may strengthen the case for multi-modal pain management programs.

Can Turning Down Alarms Improve Patient Safety?

A study from one of the intensive care units at Abbott Northwestern Hospital looked at whether changing default settings of pulse-rate alarms could improve patient safety.

By changing the thresholds, the study found that the number of pulse rate alarms dropped 76 percent within six months without any emergencies being missed.

Researchers at Dartmouth-Hitchcock Medical Center likewise observed benefits from revising default alarm settings.

Thanks, @AAMIFoundation and others, for tweeting about the Abbott story.

Alarm Fatigue, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Feb 6, 2015)

While the Patient Safety, Science & Technology Summit called for “orders of magnitude” change, the story of Amber Scott, a mother who slipped into a coma during delivery, illuminates why improving safety for even a single person matters.

Can Business Savvy, Clout, and Charisma Supercharge Patient Safety?

Medical professionals congregated at the Patient Safety Summit to support the goal of eliminating preventable medical errors by 2020.

Forbes contributors Michael Millenson and Dan Munro penned two pieces, here and here respectively, that are both worth a read—Millenson’s, for its fresh perspective as a first-time attendee, and Munro’s, for its breakdown of a rather provocative quote about “evil” people in the health care industry.

Mother Who Gave Birth During Coma on Road to Miraculous Recovery

WDSU News published a follow-up piece on Amber Scott, the woman who 2.5 years ago slipped into a coma after giving birth. Amber is well on the road to recovery as she and her husband raise their two-year old daughter Adeline.

The coma complications were related to venous thromboembolism (VTE), a leading cause of maternal morbidity and mortality in the USA.

Amber’s story, which PPAHS has previously shared, highlights the risk of blood clots for new and expectant mothers.

Risk factors for VTE can be reduced by simple and cost-effective measures. PPAHS developed OB VTE Safety Recommendations to help hospitals reduce the risk of VTE.

Standardized Alarms to Combat Alarm Fatigue

The Journal of the American Society for Blood and Marrow Transplantation and the American Journal of Nursing recently published research papers on standardized alarm care processes.

PPAHS Advisor Maria Cvach, Assistant Director of Nursing, Clinical Standards at The Johns Hopkins Hospital, has recommended standardized care processes among other possible solutions.

Alarm Fatigue, Patient Monitoring, Patient Safety, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Jan 23, 2015)

Alarms! Alarms! Alarms! … and a family seeks answers to death at a VA hospital.

But, before we get to the serious news … a little humor …

Alarm joke

(Source: The Happy Hospitalist)

The Alarm vs. Alert Conundrum

Sue Montgomery, RN, BSN, CHPN reminds us about the difference between “alarms” and “alerts”:

The terms “alarm” and “alert” are often used interchangeably, but they’re not the same thing. Alarms usually indicate a potentially life-threatening situation requiring an immediate response and are regulated by the FDA as part of the agency’s oversight of medical devices. By contrast, alerts are usually associated with non-medical devices and don’t indicate an immediate crisis. Some examples include nurse call systems and message notifications.

Alerts might be less critical than alarms, which is why they’re not regulated in the same way, but they both add to the general cacophony nurses face every day. Several studies have found that it’s difficult for most people to differentiate more than six different alarm sounds, but the American Association of Critical Care Nurses says the average ICU nurse must cope with more than three dozen sounds. It’s no wonder that alarm overload or alarm fatigue is becoming epidemic.

Alarm Fatigue and Telehealth

According to ECRI, alarm fatigue-reducing technologies and telehealth are among the top 10 technology tools hospital executives should watch for in 2015.

ECRI Institute’s 2015 Top 10 Hospital C-Suite Watch List is available as a free public service. It seeks to provide “answers [to] key questions on new and emerging health technologies that potentially provide new ways to treat patients, improve care, and reduce costs.”

Thanks to @gnayyar, @IVCiLLC, and @iHealthBlog for tweeting about this!

Man’s Family Seeks Answers After His Death at a VA Hospital

As reported by the Post Register in Idaho Falls, Idaho (note: access to the full article is only for Post Register subscribers), Richard Palmer was the victim of over-sedation after undergoing routine surgery:

Richard Palmer, awoke June 11 feeling well after undergoing routine surgery. He called his daughter at 3:30 p.m. to check in with her following the procedure.

After the operation, a catheter was placed in Palmer’s femoral nerve to administer a local anesthetic — bupivacaine — to manage his pain.

The VA later learned the pump, which regulates how fast the medicine is released, was not assembled properly, leading to the free-flow of the anesthetic for 11 minutes.

According to the medical examiner’s report, Palmer reported feeling anxious and having a tingling sensation in his feet. Then he had a seizure.

At 5:15 p.m., a blood test showed Palmer had 14 times more bupivacaine in his system than he was supposed to. At 7:29 p.m., he was pronounced dead.

Editor’s note: Use of the PCA Safety Checklist may have averted this tragedy. One of the steps to be followed before initiating, refilling, or programming change is to have two healthcare providers independently verify:

  • patient’s identification
  • all patient allergies appear prominently on medication administration record (MAR)
  • drug selection and concentration confirmed as that which was prescribed
  • any necessary dose adjustments completed
  • PCA pump settings
  • line attachment to patient and tubing insertion into pump

Sounds simple – but simple could have saved a life.

Alarm Fatigue, Patient Monitoring, Patient Safety, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Jan 16, 2015)

Achieving patient safety is the watchword for this week’s Must Reads.

2015 National Patient Safety Goals

The Joint Commission’s 2015 National Patient Safety Goals were released. Although TJC says that it has “no new Goals for 2015”, it is probably a good presentation for all healthcare facilities to look at to make sure they are meeting these objectives.

The Joint Commission 2015 National Patient Safety Goals

The first two articles may help achieve better patient safety. The latter two were shared by the Twitter health care and patient safety community – many thanks for making these Must Reads a collaborative effort.

Using Capnography to Effectively Measure How Patients Are Breathing

The Journal of Clinical Engineering discusses how Glendale Adventist Medical Center (Glendale, CA) is improving patient safety by using capnography to monitor patients during moderate sedation.

Michael O’Connor (Director of Respiratory Therapy, Glendale Adventist Medical Center) explains:

Glendale Adventist Medical Center is committed to providing the highest quality of care. Our widespread use of capnography to monitor the breathing of patients who are being sedated is in line with the latest requirements from the ASA [American Society of Anesthesiologists] and underscores our dedication to patient safety.

New Toolkit to Reduce Alarm Fatigue

The National Association of Clinical Nurse Specialists (NACNS) released a toolkit “to facilitate CNSs’ efforts to facilitate appropriate alarm management and help staff implement strategies to ensure alarm safety”.

“As leaders in ensuring evidence-based care, CNSs have an important role to play in reducing the potentially dangerous and deadly problem of alarm fatigue,” said NACNS 2014 President Les Rodriguez, MSN, MPH, RN, ACNS-BC, APRN. “Our toolkit was developed by a group of national experts whom NACNS convened to address this important issue and provide resources that will help nurses across the country combat this problem. It is intended to help guide their efforts to improve patient safety and quality of care. The toolkit includes everything a CNS needs to work collaboratively with an interprofessional team to assess the clinical environment, and then develop implement and evaluate appropriate interventions.”

New Rules to Curb ‘Epidemic’ of Cesarean Births in Brazil

From the article:

Brazil has unveiled new rules aimed at stemming the South American nation’s “epidemic of cesareans” and promoting natural births among private health care providers.

Health Minister Arthur Chioro called Brazil’s obsession with cesareans, which account for more than eight out of 10 births handled by private health providers, a “public health problem.”

Hat tip to @MinasIntl for sharing this article on Twitter. Dr. Peter Cherouny said in a past webinar “no patients are low risk” when it comes to cesarean delivery and venous thromboembolism.

Recent Research About Nursing, December 2014

“After a while, alarms stop being so alarming.”

Yikes.

Read the article here.

Hat tip to @comunikator and others for sharing this article on Twitter.

Alarm Fatigue, Patient Monitoring, Patient Safety, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Jan 9, 2015)

The Physician-Patient Alliance for Health & Safety wishes you and your loved ones a Happy and SAFE New Year!

Safety first

We particularly emphasize SAFE, because the latest news on patient safety shows that there is a lot work yet to be done … or perhaps we haven’t started? …

No Improvement in Patient Safety in Last 15 Years

HC Pro’s Patient Safety Monitor reports that, according to health experts testifying to a Senate subcommittee, that there has been no improvement in patient safety in the last 15 years:

If the truth hurts, any patient safety advocates that tuned into the Senate subcommittee hearing on patient safety were probably cringing.

No one minced words at the hearing for the Subcommittee on Primary Health and Aging on July 17, as health experts testified that patient safety has remained largely stagnant for the last 15 years. In some respects, it’s worse, failing to prevent as many as 400,000 patient deaths each year, four times more than estimates from the Institute of Medicine (IOM) in 1999.

Penalties for Hospital-Acquired Conditions

Validating this sober assessment, more than 700 hospitals “will see their total Medicare payments docked by 1 percent in fiscal 2015 as part of the first year of a federal penalty program aimed at reducing preventable harm and improving patient safety”, reports Modern Healthcare. Hospital-acquired conditions included pressure ulcers and pulmonary embolisms.

Although one would think that teaching hospitals would be the vanguard of innovation and safety, hospitals penalized include many well-known teaching hospitals – including Intermountain Medical Center, Ronald Reagan UCLA Medical Center, the Cleveland Clinic, Geisinger Medical Center, Brigham and Women’s Hospital, NYU Langone Medical Center and Northwestern Memorial Hospital.

That said, if you have a choice of hospitals, data from AHRQ’s Healthcare Cost and Utilization Project suggests that being admitted at a hospital in the West is preferable to going to one in the South:

Rates of potentially preventable hospitalizations in the United States declined 14 percent from 2005 to 2011, but rates varied widely by geographic region, according to a new statistical brief from AHRQ. Potentially preventable hospitalizations are admissions for certain acute illnesses or worsening chronic conditions that may have been avoided with higher-quality outpatient treatment and disease management. Data from AHRQ’s Healthcare Cost and Utilization Project showed that rates of potentially preventable hospitalizations in 2011 were lowest in the West (at 1,220 discharges per 100,000 population) and highest in the South (at 1,845 discharges per 100,000). Hospitals in the South had a 17.2 percent higher rate of potentially preventable hospitalizations than the overall national rate in 2005, but by 2011 it was reduced to 10.5 percent higher than the national rate.

Pregnancy-related deaths on the rise in the US

Moreover, a new study has found that even something as common as childbirth may no longer be safe:

A century ago, deaths during pregnancy or childbirth were not uncommon; however, advances in prenatal care have made great strides in increasing the likelihood of a good outcome for both mothers and their offspring. However, a new study has reported that pregnancy-related mortality has increased in recent years in the United States.

The Answer

Maureen F. Cooney, DNP, FNP, BC (Westchester Medical Center, Valhalla, NY), who spoke at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids, says the answer (at least for patients receiving opioids) is continuous monitoring. However, she reminds us that technology alone is not the answer. We also need trained bedside nurses to keep patients safe from opioids and the dangers of high-alert medications:

Continuous monitoring of patients receiving opioid therapy to prevent opioid-related respiratory depression certainly offers the hope of reducing devastating outcomes from our well-intended efforts to assure patient comfort. However, in this climate of rapid, high-tech, outcomes-driven healthcare, it is essential to keep in mind the end user—particularly the bedside nurse.

Thanks @HIEcentral for tweeting about this!

Alarm Fatigue, Patient Safety

Top 5 Alarm Fatigue Patient Safety Articles in 2014

19 out of 20 Hospitals

Of the more than 125 articles we posted in 2014, below are five of the most read and most discussed articles on alarm management (order is by publication date):

  1. Nine Technological Solutions to Manage Alarm Fatigue (March 2, 2014)

Maria Cvach, DNP, RN, CCRN (Assistant Director of Nursing, Clinical Standards, The Johns Hopkins Hospital), who is on our board of advisors, and Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety) present an Alarm Awareness Wish List of nine technological solutions to help manage alarm fatigue and to promote better alarm management. Some of these solutions exist today, while others are suggested patient safety solutions to this issue.

  1. Health Experts Discuss 4 Keys to Reducing Alarm Fatigue (May 19, 2014)

Training, education and individualization are some of the keys to better alarm management discussed by leading health experts during a webinar hosted Premier Safety Institute as part of their Advisor Live series.

  1. 10 ways to reduce alarm fatigue (May 28, 2014)

Gina Pugliese (Vice President, Premier Safety Institute), who is on our board of advisors, discusses the top 10 things you can do to reduce alarm fatigue. This is second article in a two-part series. The first is “Sounding the Alarm on Alarm Fatigue” below.

  1. Sounding the Alarm on Alarm Fatigue (May 27, 2014)

The Institute for Safe Medication Practices recently highlighted a case of a 17-year-old girl who died after a simple tonsillectomy done in an outpatient ambulatory surgery center. After the surgery, she was given a painkiller that slowed down her breathing. The drug led to respiratory depression and a fatal respiratory arrest.

Factors contributing to this tragedy included an obstructed view of the patient (a curtain had been drawn around the patient, obstructing the view necessary for the nurses to maintain an ongoing visual assessment) and a muted alarm on her monitoring equipment that couldn’t warn her nurse who was attending to another patient.

  1. ‘Alarm fatigue’ a top-of-mind concern for U.S. hospitals, finds national survey presented at Society for Technology in Anesthesia Annual Meeting (January 22, 2014)

“Alarm fatigue” – which can lead to serious and sometimes fatal consequence for patients — is rated as a top concern by 19 out of every 20 hospitals in the U.S.

Alarm Fatigue, Capnography, Patient Safety, VTE, Weekly Must Reads in Patient Safety

Top 16 Patient Safety Must Reads of 2014

This year, the Physician-Patient Alliance for Health and Safety introduced a weekly round-up of must-read articles in patient safety. The hand-picked list has consistently seen high engagement from our dear readers.

With that in mind, we thought we would compile a list of the Top Patient Safety Must Reads of 2014.

Expansion of Use of Capnography for Patient Safety
August 22, 2014

For postsurgical patients receiving opioid pain medications, effective and continuous electronic respiratory monitoring is critical. As a result, an increasing number of health care institutions are expanding their use of capnography to ensure maximum patient safety and prevent adverse events that are predictable.

To read this RT Magazine article, please click here.

National Coalition for Alarm Management Safety
August 29, 2014

The National Coalition for Alarm Management is a group of thought-leaders sharing information with other pioneers in the “alarm-management space,” driving improvement in alarm management nationwide, and seeking standardization where possible. Members come from all aspects of alarm management: the clinical community; industry; device regulators; hospital accreditors; and professional societies.

For more information on the National Coalition for Alarm Management and this month’s presentation, please click here.

Understanding healthcare’s top technology hazard
September 4, 2014

“Even with some of the world’s top device manufacturers (General Electric, Phillips, Stanley, Medline, etc.) working to develop “smart alarm” systems, the dangers are still very real. On the Emergency Care Research Institute (ECRI) Top 10 Health Technology Hazards for 2013, alarm hazards ranked number one. The issue of alarm fatigue has many facets.”

For the article, please click here.

Joan Rivers’ Death
September 12, 2014

What Killed Joan Rivers? Piecing Together a Medical Mystery

Dr Karen Sibert offers a thoughtful discussion that raises questions and offers useful information about routine procedures. As she observes, “There are minor operations and procedures, but there are no minor anesthetics. This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers.”

4 Lessons Learned from the Death of Joan Rivers

This article we co-authored with Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD). It offers 4 lessons to be learned from the death of Joan Rivers that can help others better prepare for safe medical procedures.

Capnography Outside the Operating Rooms
September 19, 2014

This article in Anesthesiology, “Capnography Outside the Operating Rooms” written by Dr Bhavani Kodali (Associate Professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School), sheds light on capnography outside the operating room.

Alarm Fatigue – Not Just an Annoyance to Nursing Staff
September 26, 2014

Hats off to @DicksonData for pointing out this article that reminds us that “noise is an environmental stressor that can have physiological and psychological effects” on patients.

C-section America’s most common major surgery?
October 3, 2014

Hats off to @JuanGrvas for asking “How did the C-section become America’s most common major surgery?” and pointing out this video by Chileshe Nkonde-Price, a cardiologist at the University of Pennsylvania, who wants to avoid an unnecessary C-sections.

Helping Hospitals Fight The Battle Against Alarm Fatigue
October 17, 2014

Robert J. Szczerba’s Forbes article made waves as it looked at alarm fatigue. As Szczerba notes:

“One of the top technologies hazards in the healthcare system is the problem of alarm fatigue, in which the sheer number, variety, and frequency of machine alarms in a hospital room leads to many of them being ignored or muted. The negative results range from annoyance to patient deaths.”

To help reduce alarm fatigue, we offer advice from members of our advisory board:

Actions Produce Results
October 24, 2014

Hats off to @TGandhi_NPSF for tweeting about this study about the affects of rounds, culture, and caregiver burnout. If leaders want to change culture and behavior, they need to be involved.

“We can’t always predict when a patient will slip from moderate sedation to deep sedation”
October 31, 2014

In this Wall Street Journal article, our own advisory board member, Frank Overdyk, MSEE, MD (Executive Director for Research, North American Partners in Anesthesiology; Professor of Anesthesiology, Hofstra North Shore-LIJ School of Medicine) reminds us:

We can’t always predict when a patient will slip from moderate sedation to deep sedation,” he says, and if the staff is unaware or inexperienced, and help isn’t available to deal with breathing and airway issues, a patient can suffer an oxygen-related brain injury “in approximately five minutes.”

Death During Childbirth
November 7, 2014

ABC news reports that “Kymberlie Shepherd, 26, died shortly after giving birth … The cause of her death was a rare amniotic fluid embolism (AFE), a leading cause of maternal mortality in the developed world.”

Kymberlie Shepherd

(Kymberlie Shepherd with her fiancé, Wayde)

Observational study counts alarms in ICUs to better understand alarm fatigue
November 21, 2014

The number of alarms collected during one month in five ICUs is “staggering” according to researchers who found that, in nearly 50,000 hours, 2.5 million unique audible and inaudible alarms occurred. The research calls for smarter monitors.

Also, hat tip to @Krista_Bones for sharing this article in Fierce Healthcare. Some good commentary by Krista, who points out that patients and families get fatigued from all the alarms—not just clinicians.

Make Health Technology Safer
November 28, 2014

In this interview with Institute for Healthcare Improvement Executive Director and patient safety expert, Frank Federico, RPh (who we are proud to say is on our advisory board) offers these tips to make health technology safer.

1.3 million adverse events prevented since 2010
December 5, 2014

The Agency for Healthcare Research and Quality (AHRQ) estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013. AHRQ attributes this to “focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.”

Modern monitoring systems contribute to alarm fatigue in hospitals, UNC study shows
December 12, 2014

Hats off to @UNC for an example of winning the battle against too many alarms.

The Value of Safer Care
December 19, 2014

A survey by Altarum Institute and Drexel University found that “most respondents would choose a hospital with a higher patient safety rating, even if it meant paying an additional $1000 in out-of-pocket costs.”

Alarm Fatigue, Patient Monitoring, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Dec 12, 2014)

Too little and too many – that’s the theme of this week’s must reads.

Too Little

Too little is known about amniotic fluid embolism – a rare but serious condition that occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as hair, enters the maternal bloodstream.

The Boston Herald reported earlier this year that Colleen Celia died shortly after giving birth to her fourth child from amniotic fluid embolism. NBC’s affiliate in Charlotte, NC, recently reported that Declan Jay Bugal “died shortly after giving birth to what doctors at the Medical Center of Aurora described as a 7-pound, 4-ounce-miracle.” Please click on the image to view the report.

Screenshot from news on a mother's death

Too Many

Hats off to @UNC for an example of winning the battle against too many alarms.

Although Jessica Zegre-Hemsey (assistant professor, UNC-Chapel Hill School of Nursing) and her team found that “more than 2.5 million alarms were triggered on bedside monitors in a single month,” in five ICU units at the UCSF Medical Center, she offered this advice to better manage the number of alarms:

If alarm settings were tailored more specifically to individuals that could go a long way in reducing the number of alarms health care providers respond to.

This advice is consistent with that given by Christopher Dandoy, MD (Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital). Dr. Dandoy led a study of alarms at his hospital and found that “up to 95% of these alarms are false—usually traceable to non-customized parameters and inadequate staff-training—and that nurses spend up to 30 minutes per shift simply dealing with false alarms.”

For further advice of managing alarms, leading health experts discussed these 4 keys for reducing alarm fatigue in a webinar hosted by Premier Safety Institute as part of its Advisor Live series.

Thanks @TodaysHospital for pointing out this study.

Alarm Fatigue, Patient Safety, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Dec 5, 2014)

The Agency for Healthcare Research and Quality (AHRQ) estimates that 1.3 million fewer patients were harmed in U.S. hospitals from 2010 to 2013. AHRQ attributes this to “focused and widespread efforts to reduce surgical-site infections, adverse drug events and other preventable incidents.”

However, Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, cautions that these numbers may not reflect actual improvements to patient safety. According to Modern Healthcare:

Pronovost said his hospital improved HAC rates by 37% in 2013 by focusing on clinical documentation and coding in response to penalties. “Yet we improved them by focusing on documentation rather than improving quality and safety,” he said. “Is this in the best interest of patients or the public? I do not think so.”

In addition, The Joint Commission and ECRI Institute both believe that more needs to be done to improve patient safety.

The Joint Commission

The Joint Commission recently added a new Patient Safety Systems chapter to its accreditation manual that requires hospitals to have an organization-wide integrated patient safety program.

ECRI Institute

In its recent report, “Top Ten Health Technology Hazards for 2015”, ECRI Institute has again named alarm hazards as the number one health technology hazard. Alarms may impede patient safety and clinician workflow:

Inappropriate alarm configuration practices—that is, the selection of values or settings that are inappropriate for the circumstances of the patient’s care—could lead to (1) caregivers not being notified when a valid alarm condition develops, or (2) caregivers being exposed to an excessive number of alarms, specifically ones that sound for clinically insignificant conditions (e.g., those that don’t require a staff response).

Skeptical Scalpel Reviews California Hospitals Adverse Events, Data Not Good

Patient safety blogger the Skeptical Scalpel, who in September wrote a guest blog on our website about whether pain is a vital sign, examined a Bay Area television station’s expose on adverse events in California hospitals. The expose found that, on average, each California hospital experiences fewer than 4 adverse events per year. Skeptical Scalpel suggests the number is under reported based on a deeper review of the data.

Alarm Fatigue, Patient Monitoring, Patient Safety

Better Alarm Management Improves Patient Safety and Clinician Workflow

Managing alarms on physiologic monitors, like pulse oximeters that measure blood oxygenation and capnography that assesses the adequacy of ventilation, is a critical patient safety issue. As the first comprehensive national survey of patient-controlled analgesia practices by the Physician-Patient Alliance for Health & Safety found, 90 percent of hospitals believe that reducing false alarms would increase use of patient monitoring devices.

ECRI

In its recent report, “Top Ten Health Technology Hazards for 2015,” ECRI Institute has named alarm hazards as the number one health technology hazard for the 4th year in a row, indicating progress on this issue has been dismal. Alarms may impede patient safety and clinician workflow:

Inappropriate alarm configuration practices—that is, the selection of values or settings that are inappropriate for the circumstances of the patient’s care—could lead to (1) caregivers not being notified when a valid alarm condition develops, or (2) caregivers being exposed to an excessive number of alarms, specifically ones that sound for clinically insignificant conditions (e.g., those that don’t require a staff response).

To better manage alarms, ECRI says clinicians and health providers need to implement appropriate alarm configuration policies and practices to minimize alarm-related adverse events:

Strategies for reducing alarm hazards often focus on alarm fatigue—a condition that can lead to missed alarms as caregivers are overwhelmed by, distracted by, or desensitized to the numbers of alarms that activate. However, alarm fatigue should not be the only factor that healthcare facilities consider when working toward improving the management of clinical alarm systems, as required in the Joint Commission’s new National Patient Safety Goal on alarm safety. In ECRI Institute’s experience, alarm-related adverse events—which can involve missed alarms or unrecognized alarm conditions—can often be traced to inappropriate alarm configuration practices. Thus, we encourage healthcare facilities to examine alarm configuration policies and practices in their alarm improvement efforts, if they have not done so already.

ECRI provides four examples of inappropriate alarm configuration practices:Alarm

  1. Failing to reset the medical device to the default alarm limits when a new patient is connected to the device. In this circumstance, the alarm limits used for the previous patient will be used for the new patient.
  2. Choosing inappropriate alarm limits for monitored parameters (e.g., heart rate, SpO2). Limits that are set too wide will prevent an alarm from activating until after the patient’s condition has deteriorated. Limits that are too narrow, on the other hand, can lead to excessive alarm activations, thus burdening staff with alarms for conditions that are not clinically significant (leading to alarm fatigue).
  3. Selecting alarm priority levels that do not match the seriousness of the condition and the required speed of response. An alarm for a condition that requires immediate attention, for example, should not be set to activate at a low priority.
  4. Not using certain arrhythmia alarms even though the patient is at risk of experiencing an arrhythmia that might require clinical intervention.

So, don’t let alarms or alarm fatigue stop you from monitoring. Develop and improve alarm configuration policies and procedures.