Our February 2013 What’s New in the Patient Safety World column “Joint Commission Proposes New 2014 National Patient Safety Goal” discussed the newly proposed NPSG dealing with alarms. Joint Commission has now published a Sentinel Event Alert dealing with alarms (Joint Commission 2013a).
We’ve mentioned before that we often make amicable bets with CEO’s when we enter their facilities that we will find within a specified timeframe some alarms that have been disabled or otherwise manipulated. It’s a problem that is obviously widespread and dangerous. But its roots are many and deep. We have far too many alarms and this leads to the phenomenon of alarm fatigue. The new Joint Commission sentinel event alert cites the statistic that between 85% and 99% of alarm signals do not require clinical intervention. Their sentinel event database has 98 alarm-related events over a little more than 3 years, 80 of which resulted inpatient death. Major contributing factors included absent or inadequate alarm systems, improper alarm settings, inaudible alarms, alarm settings inappropriately turned off, and others. They also cite events and contributing factors and recommendations from studies by ECRI Institute and the FDA and the Association for the Advancement of Medical Instrumentation.
They provide 11 recommendations that are in keeping with the newly proposed NPSG. These include involving leadership and management in developing programs of alarm management and oversight, doing an inventory of all alarms (and eliminating those not necessary), establishing guidelines for alarm settings and individualizing them for each patient or patient type, and regularly inspecting, checking and maintaining all alarms. They stress ongoing education and updates on alarmed medical devices. They recommend a multidisciplinary team lead the oversight and provide lessons learned from other organizations. They recommend using single use sensors (such as ECG leads) to reduce nuisance alarm signals. They also recommend checking the acoustics of the environment to assure alarms will be audible.
Regarding the latter recommendation we also suggest the environmental design be checked to ensure that it does not promote turning alarm volumes down. One of our earliest columns on alarm issues (April 2, 2007 Patient Safety Tip of the Week “ ”) focused on a faulty design where proximity of the ECG monitoring system to the nursing charting area often led to nurses and others turning down the volumes, eventually leading to a disastrous consequence.
Checking alarms should be a regular component of your Patient Safety Walk Rounds. More importantly, it should be something your staff does daily on every unit that utilizes alarms of any type. Some units even do it on every shift. And when you find alarms that have been disabled or otherwise manipulated make sure you find out why. Such actions always have an underlying root cause that must be addressed.
You should include alarm status as part of your structured handoff tool used at changes of shift. And alarm status must be included in your “Ticket to Ride” tool for in-hospital transports (eg. to radiology).
We also strongly recommend that any time you set up a new piece of equipment on a patient you use a checklist specific to that piece of equipment that forces you to verify that all alarms are appropriately set and functional and that parameters chosen are appropriate. We also recommend you review some of the useful tips we’ve included in our February 23, 2010 Patient Safety Tip of the Week “Alarm Issues in the News Again” and the several other columns noted below.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert 2013; 50: 1-3 April 8, 2013
The Joint Commission. Proposed 2014 National Patient Safety Goal on Alarm Management. January 15, 2013
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