Improving Clinical Alarm Safety Care Delivery Systems

Patient safety is number one in hospitals. Every staff member that comes into contact with a patient should always have the question, “Will the patient be safe?” in the back of

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

In this task I will be describing how health and safety legislation, policies and procedures promotes the safety of individuals in a Hospital. Quality care is an important issue for both health care workers and their partners. Government continue to work on implementing staffing law that will upgrade the medical systems. Hospitals are required to provide security for patients and staff. Mechanical equipment, housekeeping, administrative and food staff play important roles in preventing all environmental hazards. Safety concerns surrounding these hazards include injury, illness, disease exposure, disaster

healthcare organization accrediting bodies, and to maintain credibility with patients and peers alike, must adhere to the National Patient Safety Goals. As stated by Ulrich and Kear (2014), "Not only are nurses responsible for providing safe patient care, we are also responsible for creating an environment in which others can provide safe patient care, and for being the last line of defense when needed between the patient and potential harm. Having a deep understanding of patient safety and patient safety culture allows nurses to be the leaders we need to be in ensuring that our patients are always

The Joint Commission has instituted a number of goals nationally; the aim is to improve patient’s safety. The goals selected look at areas that are of concern in the healthcare industry particularly how it affect patients safety and make recommendations how to reduce if not eradicated these. The Joint Commission is the governing body that accredited hospitals and other health care organizations. The two hospitals that this paper will be comparing, using the goals and criteria recommended by the Joint commission, is Holy Cross Hospital located at 1500 Forest Glen Road, Silver Spring, MD and Shady Grove Hospital situated at, 9901 Medical Center Drive, Rockville, MD.

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.

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

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).

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.

False alarm is sometimes driven to unsafe actions. The nurses who must repeatedly respond to every single alarm which are mostly false leading to alarm fatigue and ignore to respond true critical alarm (Solet,& Barach,2012). The excessive alarms in patient care are distracting and interfering with the ability of the nurse to perform patient care tasks (Solet,& Barach,2012). When there are excessive of false alarms the clinicians adapt to response less or react with less urgency (Solet,& Barach,2012). Ignoring alarm can cause serious harm or death to the patients (Cvach, 2012).

With the proliferation of technology in the today’s healthcare environment, the healthcare community is increasingly concerned about the patient safety risks associated to clinical alarm hazards. In 2012, 2013, and 2014, the Emergency Care Research Institute (ECRI) identified clinical alarm hazards as a high priority potential danger area in hospitals and health systems (ECRI, 2014). The Joint Commission, the American Association of Critical-Care Nurses (AACN), the Food and Drug Administration (FDA), ECRI, and the Association for the Advancement of Medical Instrumentation (AAMI) have all identified the need to address alarm management and alarm fatigue as a priority patient safety concern (Horkan, 2014). In response to these concerns, federal regulatory mandates are increasingly coupled with recommended alarm management practices and protocols. Despite these focused efforts, alarm fatigue and alarm management continue to be priority national patient safety concerns.

Although monitors and alarms are designed with the goal of improving patient monitoring and safety, the overwhelming number of alarms on any given inpatient unit may be doing the exact opposite. The result is that healthcare workers become overwhelmed with efforts to respond to multiple alarms. A report (Mitka, 2013) concluded that many facilities do not address alarm fatigue until something goes wrong. Healthcare workers also experience desensitization, resulting in missed alarms, and delayed response to critical alarms that place patients at

As the primary provider of care for the patients that arrive at the emergency department, I play a vital role in protecting these people from harm. So important is this subject that the American Nurses Association (ANA, 2016) chose the Culture of Safety as their yearly theme in 2016. Safety as a primary goal sets the stage for all services in healthcare to fall into place. Safety starts the minute I walk onto the unit each day. The first think I do is to open my computer with a secured password.

This assignment will focus on one of the extremely important topics of the many hazards in the healthcare work place that may pose as a threat to my health and safety in the Care Industry.