Alarm Fatigue : A Critical Problem

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

B. Discussion on the process improvement plan that is likely to decrease or eliminate the reoccurrence of the outcome or scenario.

There are various examples of incidences where sleep deprivation has made 911 dispatchers issue wrong services and consequentially cause injuries or death to people needing the services. In one of the recent cases which happened in 2012, a 911 dispatcher in Maryland failed to order an ambulance despite the efforts of a woman who called to report her husband’s troubled breathing (Clarke). While the

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.

In Cvach’s (2012) article, an integrated review synthesized research and non-research findings of seventy-two articles, published between 1/1/2000 and 10/1/2011. The author used the John Hopkins Nursing Evidence Based-Practice model to measure and evaluate the articles for this review. The data collected were categorized into 5 main themes: excessive alarms and the effects on nurses, nurse's response to alarms, alarm sounds and audibility, technology to reduce false alarms, and alarm notification system (Cvach, 2012). The purpose of this integrated review was to find out if the volume of noise (false alarms vs true alarms) disrupts the nurse’s response and perception to physiologic clinical alarms. The 3 main recommendations provided by the researcher were to implement the use of smart technology, generate change within the hospital's environment and protocols, and use of precautionary measures by healthcare staff in order to reduce monitor 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

Patients want to get attendance immediately. Also, they want health care provider to treat them respect. A concept of the No Pass Zone as a patient experience initiative to provide quick and effective responses to patient’s needs originated a number of years ago from the Hospital Quality Institute (2014). This concept will assist member as needed such as picking up the glasses, reduce the risk and increase the patient satisfaction. An incident report to CHPSO stated a scenario that a custodian passed by a stable, ventilator-dependent patient’s room finding the ventilator alarming rang due to the ventilator tubing had become disconnected but no one responded until he noticed. Unfortunately, no one resuscitated this patient. If the staff could response to this alarm immediately, this patient’s condition would not be deteriorated. This accidence can be avoided. Quickly response to alarm or call bell is not only a safety concern; also it can impact patient satisfaction during hospital

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

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

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

The broad research problem leading to this study is the belief that nursing shortage in facilities leads to patient safety issues. The review of available literature on this topic shows strong evidence that lower nurse staffing levels in hospitals are associated with worse patient outcomes. Some of these outcomes include very high patient to nurse ratio, fatigue for nurses leading to costly medical mistakes, social environment, nursing staff attrition from the most affected facilities. The study specifically attempts to find a way to understand how nurse

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)

The fatigue associated with working the night shift was brought into the spotlight after an aircraft incident that occurred on June 10, 1990. British Airways flight 5390 had just departed from Birmingham International Airport when the aircraft experienced a rapid pressure loss due to the pilot’s windshield blowing out of the aircraft. This resulted in the pilot being sucked halfway out of the aircraft and another flight crew member grabbing the pilots belt and holding him from being sucked completely out while the copilot to take control of the aircraft and land it safely at a nearby airport. The official findings of the accident investigation linked the windshield blowout to the wrong size bolts being installed. The bolts were installed early in the morning hours and the fatigued shift maintenance manager who installed them didn’t recognize that they were the wrong bolts. He thought that the countersinking on the window was unusually large (Baron, 2009). This is just one example of mistakes made on night shift due to fatigue. Fatigue is a dangerous human factor that is present in the aircraft maintenance community.