April 1, 2008
Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions
When we look at our root cause analyses, we usually come up with “the big three”: (1) communication problems (2) failure to buck the authority gradient and (3) problems related to alarms. And when we are asked where to focus FMEA (Failure Mode and Effects Analysis) activities, we always mention situations where alarms are in use.
This month, the Pennsylvania Patient Safety Authority addresses both in a patient safety advisory supplement “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis”. They analyzed data on alarm-related incidents from the Pennsylvania Patient Safety Reporting System, then narrowed their focus to responses to alarm interventions related to telemetry so that they could reasonably perform a FMEA. They utilized the FMEA format recommended by Joint Commission.
Their multidisciplinary FMEA team did a great job flowcharting the alarm intervention process and identified 29 steps involved in the telemetry monitoring process. They then brainstormed to identify as many possible failure modes they could think of, prioritized the identified failure modes, and identified root causes for each of those failure modes. They then developed mitigation strategies for each and sought to redesign the processes where feasible. Because they are not a healthcare facility, they could not complete the FMEA process, which would require analyzing, testing, implementing and monitoring the redesigned process. That, of course, is extremely important because, no matter how meticulously we consider the possibility of unintended consequences, surprises often “bite back”.
Their risk priority rating scale assigned numerical equivalents for probability of occurrence, detectability, and severity and they multiplied these these 3 scores for each identified failure mode to establish priorities for developing mitigation strategies. An arbitrary cut-off score was established but they were careful to point out that not all potential failure modes nicely fit a numerical rating scheme so they allowed for circumstances where clinical and technical staff identified other practical considerations based on their experience.
We don’t want to distract you from actually going to their site and actually reading this thorough and thoughtfully done FMEA so we won’t give you all their recommendations here. However, they provide excellent recommendations regarding patient identification, optimal display location, ensuring the power source of the telemetry receivers, protocols for when monitoring is temporarily suspended or on standby (eg. during transport or while electrodes are being manipulated), protocols for alarm volume levels, electrode placements and inspection and maintenance, making alarm parameters appropriate to both the individual patient and the setting, and protocols for responding to all alarms (whether low- or high-priority alarms) including establishment of a tiered backup response system. They also point out a very important question easily overlooked in a FMEA “is telemetry monitoring indicated in this patient at all?”.
We are hard pressed to add much to their solid recommendations but do have one important recommendation. Our July 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutons” noted an adverse outcome related to transposition of telemetry receivers that were placed on two patients at about the same time. When the telemetry alarm-related incidents from the Pennsylvania Patient Safety Reporting System were analyzed, patient misidentification was one of the root causes seen fairly frequently, though it was not clear if any replicated the circumstances in the case above. We think it is extremely important that a forcing function or constraint be put in place that would preclude a nurse or technician from signing out two remote telemetry receivers at the same time. That forcing function or constraint should require that the appropriate communication and hookup to the telemetry unit occur for the first patient before the same nurse/technician could sign out a second receiver. Would that forcing function/constraint likely produce unintended consequences? For instance, what if there are two patients who emergently need telemetry monitoring? In such circumstance, both those patients would deserve one-to-one nursing care so each should have one nurse sign out one unit. And an alternative strategy would be to have a bar coding system in place whereby the patient identification is electronically communicated to the telemetry system.
As usual, the Pennsylvania Patient Safety Authority has done another excellent job of not only addressing and important, practical problem-prone area but also providing a model that healthcare organizations may look to in doing their own FMEA on any patient safety problem area.
Pennsylvania Patient Safety Authority. Patient Safety Advisory supplement “Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode and Effects Analysis”. March 2008
Patient Safety Tips of the Week pertaining to alarm-related issues:
March 5, 2007 “Disabled Alarms”
March 26, 2007 “”
April 2, 2007 “”
June 19, 2007 “Unintended Consequences of Technological Solutons”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue”