10 evidence-based alarm management strategies for clinicians
American Organization of Nurse Executives Conference (AONE)
National Rural Health Association Conference (NRHA)
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* course numbers may vary by facility
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:
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:
Swank HealthCare will be hosting its Annual Reception at the 2015 AONE Conference featuring guest speaker, Colleen Sweeney.
Wednesday, April 15, 2015
Hyatt Regency Phoenix, in the Sundance Room
April 16-17, 2015
Phoenix Convention Center- Phoenix, AZ
April 14-17, 2015
Marriott Philadelphia Downtown – Philadelphia, PA
Below are 10 evidence-based alarm management strategies for clinicians:
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