It was just a matter
of time… In response to the serious problem of alarm fatigue across the nation,
many hospitals have put in place sophisticated IT systems linking alarms to
paging or messaging systems in attempt to get prompt responses by responsible
staff to alarms. But a recent incident at a California hospital illustrates how
wrong things can go in spite of (or because of) such systems.
The case (CDPH
2015) involved a patient with hypercarbic respiratory failure who was admitted to an ICU
and put on a ventilator. As we see in most incidents resulting in patient harm,
a series of events rather than a single event led to the untoward outcome.
The alarm management
system at that hospital assigns a pager ID to a nurse and a respiratory
therapist (RT) who have primary responsibility to respond to alarms/pages for
each individual patient. But on the evening of the incident the patient
expressed her desire to have a female respiratory therapist so the RT
responsibilities were switched to another RT. But there was no change made in
the alarm management system to indicate this switch in responsibility.
Around 3:00 AM a
section of the patient’s ventilator circuit became disconnected from a
Y-connector. Heart rate and oxygen alarms went off and a series of pages/messages
were sent to an LVN (licensed vocational nurse) and an RT (respiratory
therapist). Unfortunately, the RT with responsibility for the patient never
received any such pages/messages and the RT to whom pages/messages were
erroneously sent did not respond since he did not think he had any
responsibility for this patient.
Though the patient’s
room was only 13 feet from the nurses’ station and two nurses, including the
charge nurse and the RN with primary responsibility for the patient, heard the
loud audible alarm but none responded.
Statement from the RN with primary responsibility for the
patient (who was at the nurses’ station and heard the audible alarm): “It was
just the vent alarm, it’s not like it was the oxygen saturation alarm, so I
didn’t think anything of it”. She saw the LVN go into the room. The LVN came
out of the patient’s room and called the RN for help. They found the patient
unresponsive and cyanotic and called the Rapid Response Team. Another
respiratory therapist arrived with the Rapid Response Team and found the
expiratory limb of the ventilator circuit had become disconnected from the
Y-connector. It was determined that the ventilator had alarmed for 12 minutes
due to oxygen desaturation before there was a response. The patient suffered
anoxic brain damage and subsequently died.
The charge nurse, who was also at the nurses’ station,
recalled hearing multiple alarms and did not respond to any because she was “distracted”
by the report she was receiving from another nurse. The charge nurse did see
the LVN enter the patient’s room and also recalled getting a phone call (just
prior to the Rapid Response Team call) from the technician at the alarm center
that was sending out the pages/messages stating that the patient was
desaturating.
And there was another telling quote from the respiratory
therapist to whom the alarm messages/pages were erroneously sent. While he
denied receiving any pages at all, he said “It didn’t matter if I don’t get a
page on that patient, the nurses get the pages too and they should have
responded.”
Review of the central alarm system logs showed that 23
pages/messages had been sent to the RT who had not been assigned this patient
and 24 were sent to the LVN. The pages had been sent because of both a rising
heart rate and oxygen desaturation. In addition, the alarm center technician
made 3 phone calls to the nurses’ station. The first was unanswered. The second
was answered by the nurse with primary responsibility for the patient and she
was told of the oxygen desaturation. The third was answered by the charge nurse
who was informed of continued oxygen desaturation. The Rapid Response Team
announcement went out shortly after that third call.
This unfortunate incident, of course, points out some of the
key vulnerabilities of alarm management systems.
Firstly, it points out that the hi-tech systems are only as good as the data input to them. The
computerized system appropriately sent out messages/pages to the personnel for
whom it was programmed. But it was human error and system error that led to the
failure to change the recipients after the change in assignment of RT
responsibility had occurred.
Secondly, it points out blatantly what happens when more than one person is designated as responsible
for the patient. Each assumes the other
will respond and then no one responds. And even the nurses who were almost
within arm’s length of this patient failed to respond because they expected
someone else to respond. We’ve talked about this “dual responsibility” issue before. In our October 13, 2009 Patient
Safety Tip of the Week “Slipping
Through the Cracks” we cited a paper (Singh et
al 2009) on radiology reports that demonstrated dual alerts (those sent to
both the referring physician and the primary care physician) were twice as
likely to go unacknowledged. In the current case multiple parties all assumed
someone else would respond.
There apparently was no system for escalation. A good system would escalate the messaging after a
certain time elapses without a response from the individual with primary
responsibility. In this incident the alarm system technician did escalate in
that she made phone calls to the nurses’ station when the oxygen desaturation
alarm continued. But apparently there was no formal escalation procedure in
their policy and procedure for alarm management. Perhaps the system might have
sent an initial page/message to the LVN, then a second page to both the LVN and
RN if there was no response within 1 minute, and so on. The report also does
not mention whether the RN who had primary responsibility for the patient was
even in the messaging loop (the RN was paired with the LVN because of limited
scope of practice for the LVN so both were responsible for the patient). Would
it not have been appropriate for the system to escalate the pages/messages to
that RN when others had not responded?
Note also it is not clear how this alarm management system
recognizes whether someone has responded to the patient. Presumably the central
technician would continue sending out pages/messages until the alarms stopped
alarming. The technician would not know whether appropriate responders were
already at the bedside attending to the patient.
The policies and
procedures were deficient in that they did
not clearly delegate responsibilities for responding to alarm
messages/pages. Their policies and procedures for assignment of patient
responsibilities was also deficient and there was no guidance for conveying changes in responsibility.
The hospital also had
not been tracking response times as part of their quality
improvement/patient safety monitoring. In our July 2, 2013 Patient Safety Tip of the Week “Issues
in Alarm Management” we noted one hospital found it took on average 9.5
minutes before a clinician responded to high priority alarms. Had the hospital in
the current incident been tracking such response times before the event they
might have identified and fixed problems in the system and avoided this
unfortunate outcome.
We also wonder
whether there was a knowledge deficit. The quoted comment above from the
nurse who said it was only a ventilator alarm, not an oxygen desaturation
alarm, probably had a poor understanding of respiratory physiology. This
patient was admitted with hypercarbic respiratory failure.
That means the patient might have progressive respiratory depression with hypercarbia
which would occur before significant oxygen desaturation occurred, particularly
if the patient was receiving supplemental oxygen. Perhaps other staff need
re-education on all facets of hypercarbic respiratory
failure as well.
How did the hospital respond?
1)
They implemented daily ventilator alarm response drills
2)
They implemented daily ventilator alarm checks
3)
They developed a pager assignment verification process
(each shift the supervisors for Respiratory Therapy and Nursing are to verify
pager assignment for their respective staffs)
4)
A multi-disciplinary Clinical Alarms Task Force was
convened
5)
A FMEA (Failure Modes and Effects Analysis) was
completed
6)
3 individuals were terminated (see below)
7)
Performance benchmarks were set for expected response
times to ventilator alarms
8)
Policy and procedure were revised to include
“ventilator circuit connections shall be checked by staff after repositioning,
bathing, and provision of care at the bedside”
9)
The central alarm system policy and procedure was
revised to include pager verification process steps to follow if they receive a
page on a patient not assigned to them
10) Pager
verifications to be reviewed daily
11) Several
clinical indicators to be monitored were added including: staff response to
ventilator alarms in <1 minute, pager assignment verification, internal
ventilator alarm function test, and external ventilator alarm function test
The hospital’s Plan of Correction (POC) indicated that 3
individuals had been terminated (the RN and LVN with primary responsibility for
this patient, and the RT to whom the alarm messages/pages had been erroneously
sent). Should the 3 really have been
fired? That is always a dual-edged sword. Who are the 3 individuals most
likely to never make those mistakes again? Yes, the 3 individuals you just
fired! And if during one of your ventilator alarm drills several other
individuals do not respond promptly, would you fire them? We often make the
mistake of taking one action based on the outcome of an incident and a
different one when the outcome was benign even though the same mistakes were
made in both circumstances. It may well be that other issues (eg. attitude, honesty, previous problems, etc.) played into
their decision to terminate individuals. But it is very important to root out
what was part of a problem with the safety
culture of the unit as opposed to bad actions solely accountable to
individuals. Could the same thing have happened had 3 different individuals
been in those roles that evening? We obviously don’t know those answers. But there
were certainly many upstream system defects that put those individuals in a
position to make fatal errors.
There are several other considerations if you are using alarm
management systems linking alarms to messaging/paging capabilities. One of
these has to do with battery life. In
our February 4, 2014 Patient Safety Tip of the Week “But
What If the Battery Runs Low?” we recommended that if you are using cell
phones or pagers for alerting staff to various alarms, consider doing a FMEA
(failure mode and effects analysis) and ask not only what would happen if the
primary responder’s battery is low but also what would happen if more than one
responders’ battery is low. You also need to consider that there may well be “dead zones” in your facilities where
transmission to a cell phone or other device may be blocked or otherwise
unavailable. And you’ve never misplaced
your smartphone even temporarily? Unlike anachronistic pagers that you kept
attached to your belt except to look at what number to call, today’s
smartphones or similar devices are typically used for much more than responding
to pages/messages. The more frequently you remove that smartphone from its
holster, the higher the likelihood that at some point you will put it down
somewhere and lose it.
When we do RCA’s or review RCA’s we always also try to
recognize things that were done well in addition to those not done well. In
this case the hospital did several things well immediately after the incident:
So do we think such centralized alarm management systems
linking alarms to messaging/paging capabilities are a bad idea? No. They have
the potential to add valuable defenses in combating alarm fatigue. Yet the
current incident provides many lessons learned that other hospitals need to
consider:
And we refer you
back to our July 2, 2013 Patient Safety Tip of the Week “Issues
in Alarm Management” for numerous other recommendations for your alarm
management program.
Prior Patient Safety
Tips of the Week pertaining to alarm-related issues:
References:
CDPH (California Department of Public Health). Statement of
Deficiencies/Plan of Correction. CDPH Complaint Intake Number CA00397517. 2015
http://www.cdph.ca.gov/certlic/facilities/Documents/2567_VibraHospital_IJAP_SanDiego.pdf
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of
Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern
Med. 2009; 169(17): 1578-1586.
http://archinte.ama-assn.org/cgi/content/short/169/17/1578?home
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