Alarm fatigue was a major contributor to these events due to the excessive number of alarms and high percentage of false alarms. A study at a major academic medical center found a total of more than 59,000 alarms over a 12-day period, while another study found 16,953 total alarms over an 18-day period on a single medical unit. 34 Studies have shown that the percentage of false alarms can range from 72 percent to 99 percent. 34 Safety culture Establishing a culture of safety is essential to improving overall healthcare quality. Broadly, key features of safety culture include: acknowledgment of the high-risk nature of an organization’s activities; a blame-free environment where individuals are able to report errors without fear of punishment; encouragement of collaboration across staff levels and disciplines to seek solutions to patient safety problems; and an organizational commitment of resources to address safety concerns. Addressing alarm fatigue through improving safety culture can
involve a variety of interventions that are often implemented as a system-wide or unit-wide initiative. Examples of these elements include the following: leadership ensures there are clear processes in place for safe alarm management and response; leadership establishes priorities for the adoption of alarm technology; and at all staffing levels, practices are established to share information about alarm-related incidents, prevention strategies, and lessons learned. This section reviews efforts to address alarm fatigue through improving safety culture; clinical outcome measures and provider perceptions, as well as barriers and facilitators to implementation, are examined. Improving the culture of safety in a unit or hospital can be difficult, and this PSP includes a variety of interventions involving commitment to a culture of safety by all staff at all levels, as well as changes to processes, workflows, and policies that embody this commitment. Across these varied initiatives, some common themes of facilitators and barriers emerged.
Facilitators Buy-in, especially from leadership, can greatly facilitate an effective change in safety culture. In addition to leadership commitment, securing buy- in from staff at all levels facilitates culture change. An important step in improving care is changing the culture to recognize that patient safety is everyone’s responsibility and each staff member has the duty to address alarms. Cultural change is often necessary throughout a unit to transition from alarm management being considered a nursing concern, to everyone taking responsibility for alarm management. Standardized procedures are also important for supporting a safety culture. BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2.
Instructions: Spend 10 minutes reviewing the case below and considering the questions that follow. Case Study 2: Alarm Competency
Kate Hileman, RN, MSN, knows all too well the reality behind the role alarm management plays in patient care delivery having worked as a staff nurse at the University of Pittsburgh Medical Center’s Presbyterian Hospital, which is known for organ transplantation, cardiology care, cardiovascular surgery, critical care medicine, neurosurgery, and trauma services. 35 “In 2006, following a particularly difficult shift, I met with the staff nurses for a debriefing,” Kate says. “We began discussing some of the challenges they were facing on a daily basis, and we made a list of the things they saw as barriers to providing consistent quality nursing care. It was then that the issue of excessive alarm noise came up,” The nurses, particularly on the night shift, acknowledged that alarm noise consistently pulled them away from direct patient care and that often alarm signals were too numerous for them to be able to respond in a timely fashion. Kate and a team of nurses immediately began work on a pilot project that examined the number and types of alarm signals that were occurring. They began by doing direct observations on the unit by shadowing nurses as they worked, tracking the number of alarm conditions and related signals, and their responses to them. One observer was stationed at the central monitor station and recorded all the alarm signals and corresponding conditions which occurred during an eight hour shift. They also analyzed data from the main central monitoring station to determine the number of life-threatening and non-life-threatening alarm conditions. “The results were eye opening,” says Kate. “The mid-level, non-life-threatening arrhythmia alarm conditions accounted for the majority of all alarm signals during an initial ten-day observation period and ranged anywhere from 247 to 1565 signals per day on an 18 bed medical cardiology unit. The overall average for the total observation period was 871 non-life threatening/non-actionable alarm signals per day.” The alarm signals had become background noise for nurses and other hospital staff members who have become desensitized to alarm sounds. In response to the data, non-life threatening informational alarms were set to “OFF,” permitting only heart rate parameters and life-threatening arrhythmias to produce an alarm signal. Nurses were then taught how to customize individual alarm signals based on a patient’s clinical conditions. Recognizing the challenge in customizing alarm signals for individual patients due to the lack of standardized protocols that exist today, UPMC established its own protocol consisting of “Eight Critical Elements” and an annual nursing competency review. As a result of these efforts, overall alarm signal time was reduced by approximately 80%. Since this protocol was put in place, there has been no increase in adverse patient events related to the reduction of alarm signals on non-life threatening cardiac arrhythmias.
1. Is alarm fatigue such as described in this case study a problem at your place of work?
2. Do you think the measures taken to reduce alarm fatigue at UPMC might work in your workplace setting?
3. How have you, personally, adapted to the presence of alarms of various sorts during your daily clinical work?
83
Powered by FlippingBook