Alarm Fatigue: A Case Study

Alarm fatigue is a growing national problem within the health care industry that links medical technology as a serious hazard that poses a significant threat to patient safety within hospitals across the country. Alarm fatigue occurs when nurses encounter an overwhelming amount of alarms thus becoming desensitized to the firing alarms. Alarm desensitization is a multifaceted issue that is related to the number of alarming medical devices, a high false alarm rate, and the lack of alarm standardization in hospitals today (Cvach, 2012). Desensitization can lead to delayed response times, alarms silenced or turned off, or alarms adjusted to unsafe limits, which can create a dangerous situation for the patient. Alarm fatigue

If nurses are sleepy, and burnout, they might tend to find a shortcut of giving care to the patient. These kind of shortcut can create medication errors, poor quality of care given, and can cause death.

Significance: Because nursing is the largest health care profession and nurses provide most of the patient care, and as an acute nurse, I can relate to how unsafe nurse staffing/low nurse-to-patient ratios can have negative impact on patient satisfaction and outcome, can lead to medical and/or medication errors and nurse burnout. It can also bring about anxiety and frustration, which can also clouds the nurses’ critical thinking. Most patients might not know the work load on a particular nurse and can assume that her nurse is just not efficient. Doctors also can become very impatient with their nurses because orders are not being followed through that can delay treatments to their patients. There is also delays in attending to call lights resulting in very unhappy patients who needed help.

Monitor alarms are designed to alert caregivers to changes in a patient’s condition and can save lives, but majority of the alarms do not require clinical intervention. However, as the number of alarms encountered by clinicians on a daily basis rises, it has become difficult for caregivers to distinguish between clinically significant alarms and nuisance alarms. As a result, alarm fatigue has become a serious issue, which puts patients at risk. The purpose of this paper is to discuss the research findings of two articles to explore more efficient and effective methods to reduce nurse desensitization to clinical

Alarm fatigue in health care has grown to be an ever-growing concern in the health care arena, especially when looking at patient safety concerns. There must be an understanding of the problem before we can develop policies and effective strategies to counter this problem. The concept of alarm fatigue in health care will be evaluated utilizing the method developed by Walker and Avant (2010) that identifies and gives the significance of the attributes, antecedents, and end-consequences of alarm fatigue in health care. This will be developed based

Pamela F. Cipriano, President of American Nurses Association was in disbelief to see how she has tried to enforce the Nightingale pledge of keeping patients free from harm was failed because medical errors are the third leading cause of death in the United States. As of now ANA has conducted yearlong campaign named “Safety 360 It Starts with You” in order to reduce and take measurable advances to protect the welfare of nurses and workers. It is one of campaign that the ANA comes with that is in support to both the nurses and patients. However, in the real-world nurses are stress and fatigue due to patient ratio. In my workplace, which is a state hospital, they have full time nurses on call where nurses work more than 70 hours a week. The nurses

Goal 6: Know Your Alarms. Alarms familiarity on your unit is integral to the best patient safety. Take faulty

Back in 2003, the Joint Commission created a National Patient Safety Goal due to 23 occurrences of death or injury to a patient where alarms had been applied incorrectly or the alarms had been muted (Sendelbach & Funk, 2013). By 2004, Joint Commission had removed it from their National Patient Safety Goal list and made it a requirement for Joint Commission accreditations (Sendelbach & Funk, 2013). In 2013, it was brought to the attention of the Joint Commission regarding many alarm-related events, including multiple deaths, permanent loss of function, and prolonged hospital stays due to health care worker’s decreased response times to alarms (Horkan, 2014; Joint Commission, 2013). The Joint Commission reinstated a National Patient Safety Goal in 2013 and had requirements for all hospitals that had to be met by July 1, 2014 (Joint Commission, 2013). These goals included being able to make alarm safety a priority and develop a plan to decrease the amount of alarms. This plan could include preventing unnecessary patient monitoring, clarifying who is allowed to monitor and silence alarms, setting the cardiac monitors to have multiple tones, and having a brief delay in the alarm to see if the patient can self-resolve. The second phase of the Joint Commission’s plan was to be implemented by January 2016, to where the hospital must have followed through with their designated plan (Joint Commission, 2013).

The definition of Alarm Fatigue is a situation where people become desensitized to alarms in response to excessive exposure (merriam- webster dictionary). Alarm fatigue also causes attention spans to be lowered which affects Nurses readiness for an emergency on their shift. Alarms can be overwhelming and all alarm alerts are designed differently. In an environment of constant urgency Nurses have even been described as ignoring the alarms or being negligent. There are also many different alarm terms, from false alarms and high sensitivity alarms to nuisance alarms. With so many alarm-related terms it is relevant to ensure proper understanding of these the terms to reduce risky

A fatigued nurse can lead to many errors and compromise the care given to a patient. Nurse fatigue has been found to increase depression. If a nurse has an altered mindset to begin with, they will not be able to take care of anyone else adequately. Nurse fatigue can also increase irritability. A nurse with increased irritability could lead the nurse to make irrational decisions. The nurse with sleep deprivation has an increased risk for error. A nurse is responsible for administering drugs. When a nurse is extremely tired, it could lead them to mess up the medications prescribed for the patient or to overlook reactions that the patient may experience from the medications. The nurse is also responsible for focusing on the care provided to the patient. A fatigued nurse could be too tired to notice crucial changes in the patient. The fatigued nurse will be affected in his or her performance. Nurse fatigue could also result in the nurses injuring themselves. Nurse fatigue could influence a nurse to make shortcuts and that can also endanger the nurse. For example, if a nurse has to lift a patient using a hoyer lift, but misjudges the situation because of lack of energy, the nurse could end up lifting the patient by herself and hurting her back. This is how nurse fatigue relates to the safety of the practicing nurse and patient

When nurses experience fatigue due to excessive overtime, effects that can occur are reduced decision making ability, reduced communication skills, increased forgetfulness, increased tendency of risk taking, reduced ability to handle stress on the job, decreased ability to do complex planning, and inability to recall details which can all danger patients wellbeing. Unfortunately even with all the

Horkan, A. M. (2014). Exploring the Evidence Alarm Fatigue and Patient Safety. Nephrology Nursing Journal, 41(1), 83-85.

A nurse’s typical day isn’t without stress; it is usually a lot of complex planning, critical thinking, time management, an abundance of communications with all departments of the hospital, and documenting events that have happened throughout the day on their entire patient assignment. “Nurses who are mandated following the completion of their regular shift are often ill-equipped to continue working. They have not planned for that situation with: proper advanced rest, arrangements for

Stressful work environments, long work hours and inadequate sleep all contribute to an increase in physical and mental exhaustion amongst nurses. Typically, people choose nursing as a career to help others and to make a difference in their lives, without realizing the number of duties this career demands. Nurses may suffer in silence when they are experiencing stress. The effects can impact safe and reliable care by decreasing job satisfaction, decreasing productivity, causing poor personal health, and compromising patient care. Many facilities would benefit from implementing evidence-based strategies to address nurse fatigue and burnout.

The risks of making an error were significantly increased when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week. (Trossman, 2009). Working longer hours in a high stress area will always increase the error rate. Designating an adequate number of RN positions to ensure nurses work an appropriate schedule without overtime and that their workload allows for breaks. Managerial staff must work to develop specific policies about the length of work times based on the setting, patient and provider needs. Those policies should limit nurses from working more than 12.5 consecutive hours. Provide education for all care providers on the hazards and causes of fatigue. Continue to document unsafe staffing conditions and work with others to change the current work culture so that it recognizes the effects of fatigue on patient safety, as well as the nurse. (Berger, et al. 2006)