Essay on Alarm Fatigue

In a survey carried out by the Nursing times, it was said that two thirds of Nurses believed that shortage of equipment compromises patient safety (Ford, 2010).

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

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

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).

Clinical alarm systems in acute and critical care health care settings are an assistive way to maintain communication between the client and the nurse. Awareness and comprehension of health devices is crucial to provide nurses with appropriate strategies for critical or non critical interventions that can lead to sentinel events. The ECRI, a nonprofit institute, has identified alarm hazards as the “Top Ten Health Technology Hazards” for 2014. (cite) In 2013 The Joint Commission published a Sentinel Event Alert proposing a National Safety Goal to focus on alarm safety (cite). This topic is pertinent information to be recognized and set as an achievable action in improving patient safety.

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

According to Pennsylvania Patient Safety Reporting System (PA-PSRS), nurses stated fatigue as a contributing factor to errors related to procedures, treatments, tests, and medication administrations (Gardner, Dubeck, 2016). Many "near" errors, or “close-calls” were also attributed to mental fatigue and lack of recovery time between shifts (Maust Martin, 2015). It is reported that errors and "near" errors are related to factors, such as, lapses in attention, reduced motivation, compromised problem solving, and diminished reaction time. The Joint Commission believes that fatigue is a factor that greatly contributes to the increased number of sentinel events among patients (Gardner, Dubeck, 2016).

After exposure to repetitive and continuous alarms, nurses may become desensitized or overwhelmed with the number of alarms to respond to; this phenomenon is known as alarm fatigue (Graham & Cvach, 2010). Alarm fatigue can lead to dangerous practices such as turning off alarms, silencing alarms without evaluating or troubleshooting this issue, changing the alarm parameter to unreasonably broad settings, or complete disregard of the alarm (Ulrich, 2013). A significant contributing factor is the number of duplicate or false positive alarms nurses experience each shift, with studies showing that anywhere from 72-99 percent of alarms in the clinical setting are false or non-emergent (Graham & Cvach, 2010). Although alarm fatigue is commonly associated with critical care areas, it may occur in any patient care area with frequent or repetitive alarms (Gross, Dahl & Nielsen, 2011). In addition to causing a permanent harm or death, clinical alarms also contribute to noise levels in patient care areas, which in turn can cause insomnia or delirium.

Despite the concern for patient safety amongst healthcare leaders, the American healthcare system is experiencing major problems with patient safety and medical errors. Per the World Health Organization, “as many as 1 in 10 patients are harmed whilst receiving health care”. “Approximately 43 million safety incidences occur each year”. “Medication errors costs 42 billion US dollars annually”. The connection of nurse fatigue and its adverse events on patients is substantiated in numerous studies The AHRQ performed a study that indicated shifts longer than 12 hours were substantially associated with increased nursing errors. It further

Alarm fatigue was brought into the spotlight in recent years because of adverse patient outcomes. These sentinel events triggered the Joint Commission to make alarm safety a goal in 2014, and mandating policies and procedures to be in place by 2016 for better monitoring and observance of alarms. I decided to highlight this topic since a large part of a critical care nurse’s daily routine is silencing alarms for monitors, pumps, ventilators, beds and call lights. In my personal experience inappropriately set parameters for monitors can lead to sensory overload for staff, patients and families leading to a less than desirable work and care environment. In most cases false alarms can be minimized with simple interventions, alerting staff to real situations requiring intervention.

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).