Alarm Fatigue: A Case Study

The preventable barriers identified are classified into consistent themes such as communication, interface between medical staff and fear. Aiken et al. (2002) reported that nurses contribute importantly to surveillance, early detection and timely interventions due to findings that linked association with staffing levels to patient mortality and morbidity. But higher emotional exhaustion and greater job dissatisfaction in nurses credited to the poor management of deterioration, as nurses may develop poor attitudes to intervene. Jones et al. (2006) identified lack of deterioration perception as a cause of not prompting physician review. Additionally, experiencing information overload eroded perception of deterioration as nurses felt concerned about looking stupid. Bogossian et al. (2014) supported this claim as results derived from stimulations foretold participants did not feel empowered escalate protocols as staff feared consequences, was uncertain and become deskilled in management of emergencies.

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

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

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).

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

This paper examines this culture of alarm fatigue among nurses in clinical care areas and the resulting potential for harm among the patient population. Although alarm fatigue may happen in any clinical area with frequent or repetitive alarms, this paper focuses on the phenomenon in critical care. The broad scope of this issue coupled with the high risk of patient harm demands insight and action from the nursing profession. By discussion and review of contributing factors such as repetitive alarms, noise level, lack of individualized settings, poorly configured devices, and desensitization of nurses, healthcare providers can strategize methods to prevent patient harm resulting from alarm fatigue. These measures also promote efficiency

As the technology is being implemented in health care system, computerized provider order entry (CPOE) has become the standard of care in most hospitals. According to Cherry and Jacob (2014), “CPOE contributes to safety and quality by eliminating lost orders automatically, monitoring for duplicate or contradictory orders, and reducing time to fill orders” (p 256). However, there are some barriers using the system which leads to medical errors including alarm However; some barriers are using the system which leads to medical errors including alarm fatigue, lack of communication, and clinicians’ hesitance to adapt to new system. CPOE alert physicians on a constant basis about “various drug-drug, drug-patient, and guideline-based recommendations during the ordering process” causing alert fatigue in clinicians (Payne & Weir, 2015, p 6).

Alarm fatigue is a critical problem in health care setting. Nurses may not respond to alarms because they know that most of them are false or non-actionable. Sometimes, the alarms become the noises that nurses no longer hear because they are heard all the time. In addition to ignore alarms, nurses may also reduce audible alarm levels, change alarm limits, and inappropriately silence or deactivate alarms (Cvach, 2012). The alarm fatigue has led to sentinel events and deaths of patients (Cvach, 2012). Therefore, the alarm fatigue problem has to be fixed in order to improve patient safety. This paper will introduce interventions based on evidence-based practices and leadership theories related to alarm fatigue prevention.

The focus of the red team’s project is Nurse’s Fatigue. Brunt (2017), defines nurse’s fatigue as a cognitive and physical impaired function. The cause of fatigue results from shifts longer than 12 hours or mental exertion with inadequate rest. The significance of the problem is having fatigue nurses work on the floor, endangering patients and increasing hospital errors. MacPhee, Dahinten and Havaei (2017), concluded that 89% of observed performance can potentially interrupt patient safety and diminish the nurse’s true ability in multiple levels. The health outcomes include, low-quality of patient care leading to a loss of a patient’s life, job dissatisfaction and burnout nurses. The ability to care for the patients becomes compromised resulting to an unsatisfied job performance. For instance, higher fall rates and an increase in morbidity or mortality rate. According to the ANA (2017), the statistic documentation included 50% were exhausted, 40% felt powerless with quality patient care and 26 % are frightened for their patients. The purpose of this paper is to interpret the two articles that will benefit the group’s project. This paper will describe the literature, the concept, the methods, the participants involved and the instruments used during the researcher’s study.

According to the Joint Commission 2014, clinical alarm systems are designed to alert staff for any potential patient problems, but they can jeopardize the patient safety, if they are not managed and responded properly. Nurses are known for their ability of multitasking, but everything has a limit. Due to multiple interruptions and distractions, including alarms systems, nurses develop alarm fatigue and try to tune them out and ignore them. "Alarm fatigue occurs when clinicians become desensitized and nonreactive to the sensory overload created by an overwhelming number of alarms, many of which are nuisance or non-actionable alarms” (NACNS 2013-2014).

Medicine is an always evolving field, and continues to grow in the pursuit of people health benefit. As time has passed better research studies, discoveries, treatments and improvement of patient outcomes has been the pride of the medical field. However; despite all the improvements in medical advancement, preventable medical errors have become a major problem in the field. About a decade ago, the Institute of Medicine (IOM) investigated and created the report To Err Is Human: Building a Safer Health System, in that report the IOM came to the conclusion that approximately 98,000 people has died yearly in the United States as a consequence of an preventable medical error (RWJF, 2011). Some of these errors are caused

Eric, thank you for choosing such a significant topic for your paper. Alarm fatigue is a big problem in the healthcare field. Sentinel events related to alarm fatigue is something that is totally preventable. It’s interesting our body gets trained and used to hearing certain sounds after awhile where we don’t find these sounds even bothersome. Or we have developed a way to block out these sounds and still stay focus on our task at hand. If an alarm has the option, I like to change my patient’s alarm sound to a sound that I don’t hear often so that way it quickly catches my attention and my coworkers as well during my shift. I work in the ICU where I am closely monitoring my two patients and every bed has a bed alarm built inside the mattress.

Connecting safety through communication with the help of informatics can lead to providing effective nursing care. Informatics is an expanding topic with technology being integrated more and more into health care with examples like tele health and interactive games. Therefore, the focus then changes to providing safe quality client care by gathering information. Having backup generators, and implementing a firewall system can also aid in the safe guarding of client information. Critical thinking is a skill that is used constantly in the health care field and when it comes to technology the same skill is beneficial. Coming up with new ideas on how to improve by observing what is not working is how I will make a difference for client safety measures.

In today's’ era, nurses have more responsibility than before. They are held responsible for their actions. Today’s nursing is based on basic needs of patients. Critical thinking plays an important role in nursing. Nurses are required to think and act immediately in the emergency situations. A good communication between provider is must. This could avoid the incidents to happen. Although technology has been improved as well in the past years. Now a day hospitals are more equipped than past years. The science has gone beyond the inventions to cure untreatable diseases. The art of nursing depends on how to promote wellness, to prevent illness, to facilitate coping, and to restore health. Nurses can achieve all those goals by taking a role of caregiver, educator, collaborator, advocate, and manager (Dewit O’ Neill. 4th Ed. Pg. 3-4). No one else beside nurses can better know their patients.

Hospitals are chaotic and can be difficult places to maintain safety if precautions aren’t taken. One-way that healthcare providers attempt to combat safety issues is by using different alarm systems to alert staff to issues in patient rooms. The many different alarms can be beneficial but can also cause a phenomenon that is referred to as alarm fatigue. Alarm fatigue is defined as a condition of sensory overload for staff members who are exposed to an excessive number of alarms (Blake, 2014). It is a national problem and the number one medical device technology hazard in 2012. The problem of alarm desensitization is multifaceted and could be attributed most heavily to high false alarm rates. Studies have indicated that the presence of false and/or clinically insignificant alarms ranges from 80-90% (Cvach, 2012). The constant alarms make it difficult for nurses to discern the difference between emergent and annoying alerts and can cause many to not respond as urgently as necessary.