Alarm Fatigue Research Paper

Alarm Fatigue: According to Cvach (2012), alarm fatigue is “the lack of response due to excessive numbers of alarms resulting in sensory overload and desensitization” (Cvach, 2012, p. 269). Alarm fatigue is a major concern in the critical care unit. In a course of a shift nurses hear so many alarms they began to become immune to them. There are many times when an alarm sounds the result is often a false alarm. Research has demonstrated that 72% to 99% of clinical alarms are false (Sue Sendelbach & Funk, 2013). As a result the increased number of false alarms has resulted in alarm fatigue. Alarm fatigue is when a nurse or health care professional has been exposed to an excessive number of alarms resulting in desensitization to alarms and missed alarms. As a result there has been patient injuries and deaths associated with alarm fatigue. This has raised concern making this a very important patient safety issue. Patient safety and regulatory agencies have focused on the issue of alarm fatigue, and it is a 2014 Joint Commission National Patient Safety Goal (Sue Sendelbach & Funk, 2013). This issue has raised many concerns and if not handled in a correctly fashion could result in many more incidents and sentinel effects.

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

November, 1999 brought about a release of a report prepared by the prestigious National Academy of Science’s Institute of Medicine (IOM) making medical mistakes and their magnitude of the risks to patients receiving hospital care to common public knowledge. The IOM concluded that between 44,000-98,000 deaths occur annually because of medical errors. Among a general agreement was that system deficiencies were the most important factor in the problem and not incompetent or negligent physicians and other caregivers (Sultz & Young, 2010). An excellent example of a system deficiency that leads to a crisis and sentinel event was the highly publicized overdose of Heparin to Dennis Quaid’s newborn twins in 2007.

The Merriam-Webster online dictionary (2015) defines fatigue as “a state of being very tired” (Merriam-Webster Dictionary, 2015). Stedman’s concise medical dictionary for the health professions (2001) further defines

Each year medical errors cause more than 400,000 American deaths and at least 10-20 times that number experience serious harm. Researchers say that is equivalent to “three 747 airplanes crashing each day.” Medical errors rank as the third-leading cause of death in America. Therefore, patient safety is a national concern.

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.

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 article that was chosen to write about is alarm fatigue. This article talks about all the alarms that go off on a daily basis, and the implications that can occur, such as patient death, due to the fact that, they may be ignored and not answering them. This can be very scary since it could happen on any units such as the one where the respiratory therapist works. Also, as a result of the implementation of the new charting system, which is very time-consuming, it becomes difficult to attend to the ventilator, when the alarm goes off. The article also stated that based on one research, found 72% to 99.4% of alarms that go off are false, which creates a “cry wolf” situation in which staff will respond to the alarm the percentage of time they

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).

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.

Alarm fatigue is recognized by The Joint Commission as a serious patient safety issue, with alarm mismanagement as being the root cause of alarm fatigue (The Joint Commission, 2013). Numerous regulatory and nursing organizations have published strategies to manage alarm fatigue, however evidence is lacking on the best methodology of educating nurses to alarm management. Put one or two lines of the problem the spurred this project. The aim of this study is to compare the effect of online education methodology versus traditional education methodology on the number of false and non-actionable alarm in a cardiac intensive care unit. Historically, the cardiac intensive care unit continues to have an excess number of false and non-actionable alarms despite previous attempts at raising awareness of alarm fatigue. Chapter three will describe

The safety of the patient is a worldwide issue and is not a single hospitals problem as noted by Aiken et al. (2012). According to Van Den Bos et al. (2011) some of the ways that patients could be harmed includes poor application of technology that is meant to reduce errors in health care. According to Tzeng et al., 2013 patients die unnecessarily year after year due to medical harm that can be prevented. The 2011 report by the FDA Adverse Event Reporting System (FAERS) revealed that over 98,000 of medical harm resulted in death which is about 38% of the fatalities related to medication errors (Classen et al., 2011).This has prompted the organizations and government Agencies such as Agency for Healthcare Research and Quality (AHRQ) to continually

The assumption of this study is that one methodology of educating the registered nurses to alarm fatigue and alarm management will be more effective over the other in reducing the number of false and non-actionable alarms. The expectation is to determine which educational methodology, online or traditional, will have a greater impact on the alarm management behavior of the nursing staff in the cardiac intensive care unit. This will be evident if the number of nuisance alarms are affected by one or the other educational methodology of presenting the education. The expectation is one mode of education will result in a greater reduction in the number of false and non-actionable alarms over the other. Reduction in the number of false and non-actionable alarms has been directly related to a reduction of alarm fatigue in registered nurses (Sendelbach & Funk, 2013). Evidence supports that a reduction in alarm fatigue improves patient safety and reduces the risk of patient adverse events (Sendelbach & Funk, 2013).

In today's modern world with plenty of technology, it is hard to believe that we cannot figure out how to reduce Medical errors. The issue of medical error is not new in health care organizations. It has been in spot light since 1990's, when government did research on sudden increase in number of death in the hospitals. According to Lester, H., & Tritter, J. (2001), "Medical error is an actual or potential serious lapse in the standard of care provided to a patient, or harm caused to a patient through the performance of a health service or health care professional." Medical errors

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