Alarm Fatigue Case Study
Case Study: Alarm Fatigue
Introduction This paper will analyze alarm fatigue for nurses. It will discuss a specific case that happened at a hospital in Massachusetts wherein a patient died due to his alarm being ignored. There was not only a failure of the nursing staff to answer each alarm but there was an error in the setting on the patient’s alarm indicating that he was having arrhythmia. The arrhythmia alarm was in the off position.
Regulatory Agencies The agencies involved in the investigation were the Centers for Medicare & Medicaid Services (CMS) and the state health department as well as the hospital’s own quality and safety department.
The Incident A male patient on the “surgical floor” (McKinney, 2010) died after his heart rate dropped suddenly followed by his heart stopping. Efforts to resuscitate …show more content…
How to Avoid Alarm Fatigue and Non-Compliance Alarm fatigue is a wide-spread problem. There are hundreds of alarms each day and many of them are non-emergent such as loose electrodes, low batteries, or false alarms. When there are so many of these alarms going off all day a person tends to block them out and not hear them anymore. There are numerous steps that can be taken to avoid alarm fatigue. The alarms should be set specifically for each patient, there should be enough staff to monitor and respond to an alarm, ensure that the “critical alarm sound” (Strategies for managing, 2016) can be clearly heard over other hospital sounds. Decrease false alarms by ensuring correct placement of electrodes and changing electrodes after a set amount of time to prevent degradation of the electrode pads. Ensure staff is properly trained in responding to alarms. Medical personnel must realize that alarms are only a tool to be used. They must not rely fully on these alarms to alert them to problems with the patient.
Introduction This paper will analyze alarm fatigue for nurses. It will discuss a specific case that happened at a hospital in Massachusetts wherein a patient died due to his alarm being ignored. There was not only a failure of the nursing staff to answer each alarm but there was an error in the setting on the patient’s alarm indicating that he was having arrhythmia. The arrhythmia alarm was in the off position.
Regulatory Agencies The agencies involved in the investigation were the Centers for Medicare & Medicaid Services (CMS) and the state health department as well as the hospital’s own quality and safety department.
The Incident A male patient on the “surgical floor” (McKinney, 2010) died after his heart rate dropped suddenly followed by his heart stopping. Efforts to resuscitate …show more content…
How to Avoid Alarm Fatigue and Non-Compliance Alarm fatigue is a wide-spread problem. There are hundreds of alarms each day and many of them are non-emergent such as loose electrodes, low batteries, or false alarms. When there are so many of these alarms going off all day a person tends to block them out and not hear them anymore. There are numerous steps that can be taken to avoid alarm fatigue. The alarms should be set specifically for each patient, there should be enough staff to monitor and respond to an alarm, ensure that the “critical alarm sound” (Strategies for managing, 2016) can be clearly heard over other hospital sounds. Decrease false alarms by ensuring correct placement of electrodes and changing electrodes after a set amount of time to prevent degradation of the electrode pads. Ensure staff is properly trained in responding to alarms. Medical personnel must realize that alarms are only a tool to be used. They must not rely fully on these alarms to alert them to problems with the patient.