January 2015
Swank Health: Your monthly news from Swank HealthCare


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In This Issue

Did You Know?

Clinical Alarms

Top List

10 evidence-based alarm management strategies for clinicians

What's Going On?

American Organization of Nurse Executives Conference (AONE)
National Rural Health Association Conference (NRHA)

Now Trending

See how well you can guess how participants of the survey answered the following questions

Recommended Readings

Recommended Courses*
  • #42015 Clinical Alarm Safety
  • #41914 National Patient Safety Goals: 2014
  • #311214 Medical Errors: Facility Concerns

* course numbers may vary by facility


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Did You Know?

Clinical Alarms

Did you know that federal investigators for the 2010 BP Deepwater Horizon Oil Spill that killed 11 people and resulted in a $40 billion economic loss, found that vital warning systems on the oil rig were turned off at the time of the explosion to spare workers from being woken by false alarms? Sadly, it’s true, but if you’re wondering what that has to do with medical care, there are many sad-but-true events of patient harm, including death, that result from disabled and other alarm hazards in hospitals and healthcare facilities across the nation.

The U.S. Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database revealed 566 alarm-related hazards, resulting in 35 patient deaths reported between January 2005 and June 2010 and industry experts say the actual numbers are likely higher. In 2012, the ECRI Institute ranked alarm system-related hazardous situations as number 1 on the Top 10 List of Health Technology Hazards. The Joint Commission’s Sentinel Event Database includes reports of 98 alarm-related events between January 2009 and June 2012. Of those, 80 resulted in death and 13 in permanent loss of function.

Alarm systems are built into many types of medical technologies, such as infusion devices, ventilators, and telemetry monitors. When they work as intended, they alert clinicians to changes in patients’ conditions or problems that require decisions and action to prevent patient harm. Alarm fatigue happens when too many alarms occur in a clinical environment, causing clinicians to unconsciously tune-out or become desensitized to alarm sounds. The average number of alarms in an ICU increased from 6 in 1983 to more than 40 different alarms in 2011. Reports claim that more than 350 alarms per patient day result from monitoring systems in acute care environments, but less than 5% require clinical intervention to avoid patient harm. That means that 95% of alarms are false-positive or nuisance alarms. The greater the numbers of these types of alarms, the more likely clinicians are to lack urgency in responding to alarms, become desensitized and tune them out, or disable them to prevent them from sounding.

In June 2013, The Joint Commission approved a new National Patient Safety Goal on clinical alarm safety for hospitals. Phase I of the goal began in January 2014 requiring hospitals to establish alarms as an organization priority and to identify the most important alarms to manage based on internal situations. The identification process required:

  • Input from medical staff and clinical departments
  • Assessment of patient risks if alarm signals are not attended to or if they malfunction
  • Assessment of specific alarm signals that are needed and those that unnecessarily contribute to alarm noise and alarm fatigue
  • Assessment of potential for patient harm related to alarm based on internal incident history
  • Identification of best practices and guidelines

Phase II begins in January 2016 and will require hospitals to develop and implement specific components of policies and procedures and education for staff on alarm system management. Policies should be based on information gathered in Phase I and, at a minimum, must address:

  • Clinically appropriate settings for alarm signals
  • When alarm signals can be disabled
  • When alarm parameters can be changed
  • Who in the organization has the authority to set, and/or change alarm parameters
  • Who in the organization has the authority to set alarm parameters to “off”
  • Monitoring and responding to alarm signals
  • Checking individual alarm signals for accurate settings, proper operations, and detectability

What's Going On?

American Organization of Nurse Executives Conference (AONE)

Swank HealthCare will be hosting its Annual Reception at the 2015 AONE Conference featuring guest speaker, Colleen Sweeney. Wednesday, April 15, 2015
6:15pm -8:15pm
Hyatt Regency Phoenix, in the Sundance Room

April 16-17, 2015
Phoenix Convention Center- Phoenix, AZ

More Information »

National Rural Health Association Conference (NRHA)

April 14-17, 2015
Marriott Philadelphia Downtown – Philadelphia, PA

More Information »


Recommended Readings

Swank HealthCare provides the ability to upload unlimited custom content in the LMS.


Top List

Below are 10 evidence-based alarm management strategies for clinicians:

  1. Clean ECG electrode areas with soap and water, wipe with a rough washcloth or gauze, and use the sandpaper on the electrode to slightly roughen a small area of the skin. Do not use alcohol for skin preparation as it can dry out the skin. Hair at the electrode site should be clipped
  2. Change ECG electrodes daily or more often if needed to maintain good skin contact.
  3. Customize ECG alarm parameters to meet the needs of the individual patients.
  4. Set customized ECG alarms within 1 hour of assuming care of a patient and as the patient’s condition changes.
  5. Collaborate with a multidisciplinary team, including biomedical engineering to determine best delay and threshold settings for pulse oximetry monitors.
  6. Use disposable, adhesive pulse oximetry sensors and replace when they no longer adhere properly to the patient’s skin.
  7. Provide education on alarm monitoring systems and operational effectiveness to new nurses and periodically to other healthcare staff.
  8. Establish alarm policies and procedures, with input from interprofessional teams that address default alarms on equipment and standardized monitoring practices across clinical areas. Consider developing a culture of suspending alarms when clinicians perform care that may produce false claims.
  9. Collaborate with an interprofessional team to determine which patients in a population or care area who should be monitored and what parameters to use.
  10. Use the American Heart Association’s Practice Standards for ECG Monitoring in Hospital Settings: Executive Summary and Guide for Implementation.

Now Trending

In 2011, The Healthcare Technology Foundation performed a national survey of healthcare personnel on clinical alarm issues.

See how well you can guess how participants of the survey answered the following questions.

What percentage of survey participants agreed that clinical policies on alarm management were effectively used in their facility?

A. 95%
B. 75%
C. 55%
D. 35%

What percentage of survey participants agreed that nuisance alarms occur frequently?

A. 96%
B. 76%
C. 66%
D. 46%

What percentage of survey participants agreed that nuisance alarms reduce trust in alarms and cause caregivers to inappropriately turn alarms off at times other than setup or procedural event?

A. 98%
B. 78%
C. 48%
D. 28%


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Answer: B – 76%

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Answer: B - 78%

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