Improving Clinical Alarm Safety Care Delivery Systems

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Improving Clinical Alarm Safety
The topic I have chosen for my Portfolio Project is “Improving clinical alarm safety in hospitals.” As a member my organization’s Quality Improvement Team, I have been recently involved in an initiative to establish “alarm safety” as a priority for leadership of our hospital. My interest in the success of this initiative stems from a strong desire to be involved in the development of “safe” patient care delivery systems. As I research this topic and “problem” further, I will be examining the various published recommendations and best practices, proposed by various healthcare safety organizations, to develop processes for safe alarm management in high risk areas of the hospital. I will also propose
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Many of these alarms do not require that a medical intervention be performed, and nurses and other patient care providers can become overwhelmed by the volume of alarms they must respond to. Clinicians report being desensitized or immune to the signals over time, sometimes inappropriately turning down the volume or adjusting the settings outside of “safe’ limits. These situations can result in serious consequences, including death. The Joint Commission Sentinel Event database contains 98 reports of alarm related events between January 2009 and June 2012 (TJC, 2013). Patient death was the end result in 80 of these events. In addition, the Food and Drug Administration (FDA) database contains 566 alarm related patient deaths in a four year period, between January 2005 and June 2010 (ECRI, 2013). In a survey of hospital leaders conducted by The Joint Commission in 2012, fewer than 50 percent had an organization-wide process for alarm management.
Identified Patient Risks
Nurses often compare their patient care environments to a casino or carnival; a cacophony of sounds and little distinction of where these sirens originate and what they mean (Cadet, 2014). Clinicians cope by turning alarms down or off to create a more tolerable environment for themselves and their patients. Unfortunately, all too often this results in harm to the patient. In a recent survey by the Health¬care Technology Foundation (2011), one in five respondent hospitals identified an avoidable
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