Alarm Fatigue Research Paper
The Adverse Effects of Clinical Alarms: Alarm Fatigue
Juleen Barnes
Maria Galo-Parrilla
Harriet Meulendyke
Elynor Furlan
HSN 510
February 23, 2015
Delores Deihl
The Adverse Effects of Clinical Alarms: Alarm Fatigue
Technology has taken over the patient’s bedside. The sounds of ventilator alarms, cardiac monitors, and infusion pumps are only a few reverberations heard through the halls of any hospital. As we attempt to protect our patients by using sophisticated technology, device alarms place them in danger. Constant alarms sound in the hospital lead to staff desensitization, complacency, and distraction, which eventually can lead to ‘alarm fatigue’ (Tanner, 2013). Alarm Fatigue Alarm fatigue is prevalent in every hospital worldwide. …show more content…
The frequency of false alarms encourage staff to modify the device to reduce false or clinically insignificant alarm activation (Cvach, 2012), creating an opportunity for inattention, avoidance and potential for untoward patient events. This phenomenon can be referenced as “The Boy, who cried wolf” consequence (RN.com, 2013). The Joint Commission is so concerned about alarm fatigue and its relation to serious safety events that it has designated it a National Patient Safety Goals (Zhani, 2015). It is estimated that 85-99 percent of all alarms do not require clinical intervention (Wyatt, 2015). Minimizing clinical alarms, incorporating assessment skills, monitoring, and implementing interventions are some ways to help prevent alarm fatigue. Implications Alarm fatigue can lead to poor quality care and adverse patient outcomes (Horkan, 2014). Staff become mentally fatigued when they are exposed to a large number of signals, which creates sensory overload, leading to a slow or non-existing response to signals (Horkan, 2014). Cvach notes “medical devices generate enough false alarms to cause a reduction in response, leading to staff disabling devices, caregiver apathy and profound desensitization to real events are less likely to be acted upon”(2012, p. 268). These nuisance alarms become a problem because it interrupts patient care and distracts staff. When false alarms occur, they lead to distrust of the alarm system, and a lack of response, directly reducing patient’s safety rather than improving it (Horkan, 2014). The Joint Commission noted in Issue 50 of Sentinel Event Alert, (April 3,2012) “the Sentinel Event database reports 98 alarm related events, of those 80 resulted in death, 13 in permanent loss of function, and five unexpected extended stays” (para. 3). Of note, casualties were, “… medication errors, falls, ventilator use and delays in treatment” (Sentinel Event Alert, 2012. Para 3). These sentinel events were directly attributed to alarms not being set correctly, turned off, malfunctioning, or other device modification (Horkan, 2014).
Minimizing Distraction Alarm fatigue may be minimized by reducing the number of alarm signals and by using the medical equipment alarm system effectively (Horkan, 2014). Withdrawing nuisance alarms will allow the staff to be alert to real alarms (Horkan, 2014). An example of minimizing system alarms is visually to assess venous and arterial access sites and dialyzers for signs of infiltration and clotting during dialysis. Modifying audible alarms based upon priority is another modification technique that can be employed. The staff would be alert to the urgency of a particular signal requiring immediate attention (Cvach, 2012).
Reason for Selection Using medical devices to detect adverse patient events are to augment patient surveillance and safety.
Alarm fatigue is an unintended negative discovery in the pursuit of patient safety. Reliance on the machine rather than the human is a dangerous pitfall and steps to avoid it need implementation. Creating alarm protocols may help to decrease adverse effects of alarm fatigue (Horvath, 2014). For actual patient monitoring, nurses should rely on the fundamentals of the nursing process. These simple steps can aid in eliminating alarm fatigue and ensure the safety of patients (Horkan, 2014).
References
Cvach, M. (2012, July/August). Monitor alarm fatigue an integrative review. Biomedical Instrumentation & Technology, 46(4), 268-277. ProQuest database.
Horkan, A. (2014). Alarm fatigue and patient safety. Nephrology Nursing Journal, 41(1), 83-85.
Tanner, T. (2013, June). The problem of alarm fatigue. Nursing for Women’s Health, 17(1), 153-157.
The Joint Commission. (2013). The joint commission. Retrieved from http://www.jointcommission.org
RN.com. (2014). Retrieved from http://www.rn.com/pages/resourcedetails.aspx?id=3417
Wyatt, R. (2015). The Joint Commission. Retrieved from http://www.jointcommission.org/jc_physician_blog/the_alarming_world
Zhani, E. (2015). The Joint Commission. Retrieved from
http://www.jointcommission.org/new_joint_commission_alert_addresses_medical_device_alarm_safety_in_hospitals/
Juleen Barnes
Maria Galo-Parrilla
Harriet Meulendyke
Elynor Furlan
HSN 510
February 23, 2015
Delores Deihl
The Adverse Effects of Clinical Alarms: Alarm Fatigue
Technology has taken over the patient’s bedside. The sounds of ventilator alarms, cardiac monitors, and infusion pumps are only a few reverberations heard through the halls of any hospital. As we attempt to protect our patients by using sophisticated technology, device alarms place them in danger. Constant alarms sound in the hospital lead to staff desensitization, complacency, and distraction, which eventually can lead to ‘alarm fatigue’ (Tanner, 2013). Alarm Fatigue Alarm fatigue is prevalent in every hospital worldwide. …show more content…
The frequency of false alarms encourage staff to modify the device to reduce false or clinically insignificant alarm activation (Cvach, 2012), creating an opportunity for inattention, avoidance and potential for untoward patient events. This phenomenon can be referenced as “The Boy, who cried wolf” consequence (RN.com, 2013). The Joint Commission is so concerned about alarm fatigue and its relation to serious safety events that it has designated it a National Patient Safety Goals (Zhani, 2015). It is estimated that 85-99 percent of all alarms do not require clinical intervention (Wyatt, 2015). Minimizing clinical alarms, incorporating assessment skills, monitoring, and implementing interventions are some ways to help prevent alarm fatigue. Implications Alarm fatigue can lead to poor quality care and adverse patient outcomes (Horkan, 2014). Staff become mentally fatigued when they are exposed to a large number of signals, which creates sensory overload, leading to a slow or non-existing response to signals (Horkan, 2014). Cvach notes “medical devices generate enough false alarms to cause a reduction in response, leading to staff disabling devices, caregiver apathy and profound desensitization to real events are less likely to be acted upon”(2012, p. 268). These nuisance alarms become a problem because it interrupts patient care and distracts staff. When false alarms occur, they lead to distrust of the alarm system, and a lack of response, directly reducing patient’s safety rather than improving it (Horkan, 2014). The Joint Commission noted in Issue 50 of Sentinel Event Alert, (April 3,2012) “the Sentinel Event database reports 98 alarm related events, of those 80 resulted in death, 13 in permanent loss of function, and five unexpected extended stays” (para. 3). Of note, casualties were, “… medication errors, falls, ventilator use and delays in treatment” (Sentinel Event Alert, 2012. Para 3). These sentinel events were directly attributed to alarms not being set correctly, turned off, malfunctioning, or other device modification (Horkan, 2014).
Minimizing Distraction Alarm fatigue may be minimized by reducing the number of alarm signals and by using the medical equipment alarm system effectively (Horkan, 2014). Withdrawing nuisance alarms will allow the staff to be alert to real alarms (Horkan, 2014). An example of minimizing system alarms is visually to assess venous and arterial access sites and dialyzers for signs of infiltration and clotting during dialysis. Modifying audible alarms based upon priority is another modification technique that can be employed. The staff would be alert to the urgency of a particular signal requiring immediate attention (Cvach, 2012).
Reason for Selection Using medical devices to detect adverse patient events are to augment patient surveillance and safety.
Alarm fatigue is an unintended negative discovery in the pursuit of patient safety. Reliance on the machine rather than the human is a dangerous pitfall and steps to avoid it need implementation. Creating alarm protocols may help to decrease adverse effects of alarm fatigue (Horvath, 2014). For actual patient monitoring, nurses should rely on the fundamentals of the nursing process. These simple steps can aid in eliminating alarm fatigue and ensure the safety of patients (Horkan, 2014).
References
Cvach, M. (2012, July/August). Monitor alarm fatigue an integrative review. Biomedical Instrumentation & Technology, 46(4), 268-277. ProQuest database.
Horkan, A. (2014). Alarm fatigue and patient safety. Nephrology Nursing Journal, 41(1), 83-85.
Tanner, T. (2013, June). The problem of alarm fatigue. Nursing for Women’s Health, 17(1), 153-157.
The Joint Commission. (2013). The joint commission. Retrieved from http://www.jointcommission.org
RN.com. (2014). Retrieved from http://www.rn.com/pages/resourcedetails.aspx?id=3417
Wyatt, R. (2015). The Joint Commission. Retrieved from http://www.jointcommission.org/jc_physician_blog/the_alarming_world
Zhani, E. (2015). The Joint Commission. Retrieved from
http://www.jointcommission.org/new_joint_commission_alert_addresses_medical_device_alarm_safety_in_hospitals/