Description And Scope Of The Problem

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

Sentinel events are a major cause of deaths in hospitals, these deaths may have been prevented if there was not a break down in the communications process. Due to the rise of such events it has been decided that by the Commission that National Patient Goals would include patient safety as an area of focus.

378). Hospitals have an array of medical devices at the bedside that have alarms, which have grown significantly within recent years. Nurses may be exposed to over 350 physiologic alarm monitors per day, resulting in sensory overload thus leading to desensitization. When the alarm sounds it should be corrected immediately, even though it may be a false alarm or no issues with the patient. The Joint Commission has identified alarm fatigue as a 2014 National Patient Safety Goal, requiring hospitals “to establish improvement of alarm system safety as an organization priority” (as cited in Horkan, 2014, p. 83). Alarms are deliberately designed for high sensitivity so that nurses do not miss a true event. Firing alarms are usually muted, disabled or ignored by nurses altogether because alarms are viewed as a nuisance. Alarm hazards have generated national attention, in one highly publicized case an alarm sounded for 75 minutes before a nurse responded to a patient’s heart monitor that needed a battery replaced. When the nurse finally went to change the battery the patient was found unresponsive and could not be resuscitated because he had gone into cardiac arrest (Sendelbach & Funk, 2013). The patient’s heart monitor battery eventually died and did not issue the critical alarm alert. In another event, a patient fell getting out of bed and bleed to death because the nurse

The following are the National Patient Safety Goals for 2016: improve the accuracy of patient identification, improve the effectiveness of communication of caregivers, improve the safety of using medications, reduce the harm associated with clinical alarm systems, reduce the risk of health care- associated infections, and for the hospital to identify safety risks inherent in its patient population (Hudson 2016 page 2). Under each category there are specific goals, such

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

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

The Joint Commission also addresses safety issues through the publication and distribution of the Sentinel Event which identifies a severe breach in safety and addresses ways on how to improve processes and to prevent harm in the future. It also publishes the National Patient Safety Goals which address healthcare safety and ways to solve problems that focus on issues such as identifying patients correctly, improving communication among staff, and administering medications safely, just to name a few. “A majority of Joint Commission standards are directly related to safety, addressing such issues as medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staffing and staff competence, fire safety, medical equipment, emergency management, and security. The standards also include requirements for preventing accidental harm; responding to patient safety events; and the organization’s responsibility to tell patients about the outcomes of their care” (TJC,

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.

Over the last several years, a wide variety of health care organizations have been facing a number of challenges. This is because of pressures associated with: rising costs, increasing demands and larger numbers of patients. For many facilities this has created a situation where patient safety issues are often overlooked. This is because the staff is facing tremendous amounts of pressure, long hours and more patients. The combination of these factors has created a situation where a variety of hospitals need to improve their patient safety procedures. In the case of Sharp Memorial Hospital, they are focused on addressing these issues through different strategies. To fully understand how they are able to achieve these objectives requires looking at: specific ways the organization has responded to the crisis in medical errors, their definition of patient safety, the causes of errors, systematic barriers and transformations that have been adopted. Together, these different elements will provide the greatest insights as to how the facility is coping with the crisis in patient safety.

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

Virginia Mason used VMPS principles to develop a Patient Safety Alert (PSA) system requiring all staff who encounter a situation likely to harm a patient to make an immediate report and “stop the line” (i.e., cease any activity that could cause further harm). If the safety of a patient is indeed at risk, an investigation is immediately launched to

In order for a new medical equipment alarm design to be accepted, it needs to pass a predetermined set of standards. As the engineers introduce more new and different functions to alarms, they also have to include more ways to distinguish these functions in order that they still meet the standards for building these equipment. One standard is called IEC 60601-1-8, which was introduced in 2003. It is a complete international standard that “specifies basic safety and essential performance requirements and tests for alarm systems in medical equipment” (O’Brien 3). The IEC 60601-1-8 completion is not a requirement, but it is expected that the engineers pick up this standard with every machine they make. In not following it, manufacturers risk