What’s New in the Patient Safety World
May 2013
Joint Commission Sentinel Event Alert: Alarm Safety
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 “More Alarm Issues”) 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:
- March 5, 2007 “Disabled Alarms”
- March 26, 2007 “Alarms Should Point to the Problem”
- April 2, 2007 “More Alarm Issues”
- 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”
- March 16, 2010 “A
Patient Safety Scavenger Hunt”
- November 2010 “Alarms in the Operating Room”
- February 22, 2011 “Rethinking
Alarms”
- February 2013 “Joint
Commission Proposes New 2014 National Patient Safety Goal”
References:
The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert 2013; 50: 1-3 April 8, 2013
http://www.jointcommission.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF
The Joint
Commission. Proposed 2014 National Patient Safety Goal on Alarm Management.
January 15, 2013
http://www.jointcommission.org/assets/1/6/Field_Review_NPSG_Alarms_20130109.pdf
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