What’s New in the Patient Safety World
November 2010
Alarms in the
Operating Room
We have discussed problems with alarms on numerous occasions. In our February 23, 2010 “Alarm Issues in the News Again” we noted that alarm fatigue is a real problem. Just as we see “alert fatigue” when physicians are exposed to too many alerts and reminders during CPOE, “alarm fatigue” refers to the human tendency to begin ignoring alarms when exposed to a constant bombardment by alarms, many of which are false alarms or not clinically important. We noted a study by Siebig and colleagues (Siebig et al 2010) in medical intensive care units that found only 15% of alarms were considered clinically relevant. That article and the accompanying editorial (Blum 2010) call for future research into alarms and suggest development of monitoring algorithms that could monitor multiple physiological parameters simultaneously to identify clinically relevant changes earlier and more reliably. They also suggest using different audible tones to help differentiate various signals indicating problems with the electrodes versus problems with the patient.
Now a new study (Schmid 2010) looked at alarms in 25 consecutive cardiac surgery cases. They noted an average of 1.2 alarms per minute and noted that approximately 80% of the alarms had no therapeutic consequences, a figure remarkably similar to that found in the Siebig study mentioned above. As noted in the title of this article, the “crying wolf” phenomenon may occur when alarm fatigue leads to ignoring critical alarms that do have clinical consequences.
Ignoring alarms is one of our “big three” contributing factors we commonly encounter when doing root cause analyses of events with advere outcomes. But ignoring alarms usually has its own root causes, most important of which is alarm fatigue. Clearly, we need to look at alarms in virtually every clinical venue and critically assess whether the alarms are needed and whether the net effect of the alarms is beneficial or simply a distraction.
Previous 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”
References:
Schmid F, Goepfert MS, Kuhnt D, et al. The Wolf Is Crying in the Operating Room: Patient Monitor and Anesthesia Workstation Alarming Patterns during Cardiac Surgery. Anesth Analg 2010; ANE.0b013e3181fcc504; published ahead of print October 21, 2010, doi:10.1213/ANE.0b013e3181fcc504
http://www.anesthesia-analgesia.org/content/early/2010/10/21/ANE.0b013e3181fcc504.abstract
Siebig S, Kuhls S; Imhoff M, et al. Intensive care unit alarms - How many do we need? Critical Care Medicine 2010; 38(2): 451-456
Blum JM, Tremper KK. Alarms in the intensive care unit: Too much of a good thing is dangerous: Is it time to add some intelligence to alarms?
Critical Care Medicine 2010; 38(2): 702-703
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