In September 2013, a study published in the Journal of Patient Safety estimated medical errors leading to patient death to be much higher than previously believed”from 210,000 to 400,000 deaths per year. The Centers for Disease Control and Prevention (CDC) noted that those figures would make medical errors the third leading cause of death, behind heart disease and cancer.
A recent report by the U.S. Emergency Care Research may shed some light on the problem. Medical device alarms, it says, remain a leading technological hazard in hospitals, and lead to alarm fatigue in caregivers that can result in delayed treatment and patient harm. The FDA stated in January 2011 that from 2005 through 2008, they received reports of 566 patient deaths related to the alarms on monitoring devices.
Too Many Alarms
Medical devices sound hundreds of alarms per patient per day. These constant sounds distract and desensitize medical workers, creating alarm fatigue. Caregivers are more likely to ignore the alarms and lose their ability to tell the difference between them, which increases the risk they may miss an important alarm that really requires their attention.
A different manufacturer makes each of the devices, each equipped with alarms. One patient room may have dozens of pieces of equipment, all with different alarm sounds. Barbara Drew, a professor in the UCSF School of Nursing, researched the issue, analyzing about 7,000 heart rhythm alarms generated during the month of March at UCSF. Results showed that 87 percent of the alarms were false”meaning no true medical crisis existed when they sounded.
In April 2013, the Joint Commission issued a Sentinel Event Alert asking leaders at hospitals to take a focused look at this serious patient safety issue.
Joint Commission Makes Suggestions
What can be done to solve this problem? The Joint Commission suggests the following:
¢ Ensure there is a process for safe alarm management and response in areas identified by the organization as high risk.
¢ Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and the limits appropriate for each care area.
¢ Establish guidelines for alarm settings on alarm-equipped medical devices; identify situations when alarm signals are not clinically necessary.
¢ Establish guidelines for tailoring alarm settings and limits for individual patients.
¢ Inspect, check and maintain alarm-equipped medical devices to provide for accurate and appropriate alarm settings, proper operation, and detectability.
They also recommend training and education for all clinical care team members on safe alarm management and response in high-risk areas.
Working with Existing Systems
The Boston Medical Center (BMC) recently succeeded in reducing its weekly audible cardiac alarm rate by 89 percent, according to a new study in the Journal of Cardiovascular Nursing. Among other steps, they changed alarms for heart attack and heart rate limits to crisis, which means nursing staff had to view and act on the alarms each time they sounded. They also eliminated self-resetting alarms.
Director of clinical engineering at BMC, James Piepenbrink, stated that while some hospitals are looking to add technology to combat alarm fatigue, BMC’s approach showed that clinicians can interact with current alarm systems more effectively to decrease clinical alarm fatigue while still keeping patient safety a priority.
