Clinical alarms can be a nuisance… and a lifesaver
Karyn Temte Lloyd, RN, BSN, CPHQ
Quality management coordinator
July 16, 2014
In a heart-wrenching TED Talks video, a young mother describes how she lost her 20-month-old son to a medical error at a well-respected national hospital.
A nurse had turned off an alarm to the toddler's heart and oxygen-saturation monitor to help his exhausted mother get some needed rest. Unbeknownst to the nurse, this action had turned off not just the room alarm, but all the monitoring system's alarms. When the young boy's heart stopped beating, the critical alarm that warns of a life-threatening event was silent.
Incidents like this and others have prompted The Joint Commission to place greater emphasis on alarm management in hospitals, and the threat that improperly managed alarm systems pose to patient safety.
In January the commission issued a patient safety goal on alarm management, which requires systematic reviews by health care systems across the nation. Recent research indicates only 1 to 15 percent of alarms require clinical intervention. The other 85 percent of alarm beeps and whistles create "alarm fatigue," increasing the chance that staff will ignore important alarms.
Improving alarm management for patient safety involves the complete review of all clinical alarms, prioritizing critical alarms, developing policies to guide practice, thereby reducing the inherent drain of noise fatigue for staff.
Sandra Maddux, regional director of nursing practice, is leading the Oregon Region by convening an interdisciplinary group to improve and manage the clinical safety of alarms.
Although Providence's Oregon hospitals meet The Joint Commission's standards for managing alarms, the workgroup found alarm management to be complex. Increasing the awareness of clinical providers and staff about alarm management is an important facet of this work.
Current research will be used to model our process development after successful programs across the nation. The workgroup's first step is a survey of clinical staff, observation of clinical alarms on units and biomedical equipment inventory to gather data of clinically significant alarms. This information will bring the group closer prioritizing critical clinical alarms.
By January 2016 The Joint Commission will require health care facilities to have clinical alarm-management policies and to have completed staff education and training on these policies. As this important work continues at Providence throughout this year and next, licensed independent providers and staff will be informed of our progress and included in the process to determine critical alarm policy and practice.
Other accreditation news
- The Oregon Region is standardizing peer review charters, forms and criteria. Providers will be kept informed as this work progresses.
- HealthStream modules will be used for initial and annual LIP education for ease of access and consistency of practice. More information will follow as the task force completes this work.