In 2010, national attention to alarm safety was gained after and adverse event occurred in Massachusetts that involved the death of an 89-year-old man. This death was attributed to an alarm that had been inadvertently turned off; therefore, staff was unaware of the changes in his heart rate the ultimately lead to his death (Drew et al., 2014; ERCI Institute, 2013). According to The Joint Commission (TJC) Sentinel Event Database, from January 2009 through June 2012 there were 98 alarm related events; 80 of which resulted in death (The Joint Commission, 2013). In 2013, TJC announced a National Patient Safety Goal (NPSG) for 2014 highlighting the need to examine and improve monitor technology and reduce the number of nuisance alarms (ERCI
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The purpose of the NPSG is to attract attention to alarm hazards and to focus on the development of a systematic approach to identifying solutions that have the most direct relationship to patient safety (“The Joint Commission announces,” 2013). The goal is outlined in two phases: Phase I requires hospitals to recognize alarms as an organizational priority and to isolate the most important alarms to be addressed. Phase II, which needs to be implemented by January 2016, requires organizations to have specific policy and procedures established that are directed towards solutions for alarm management (Sendelach, Wahl, Anthony, & Shotts, 2015; “The Joint Commission announces,” 2013). In addition, The ERCI Institute has identified alarm hazards on their Top 10 Health Technology Hazards since 2007 and recommends a thorough assessment of alarm management (ERCI Institute, 2013). This national awareness underscores the importance of aggressively addressing the complex issues surrounding alarm safety and promotes healthcare institutions to find solutions that mitigate the risk associated with the discordant mixture …show more content…
The institution uses default parameters that are set by the technology companies. These parameters are not tailored to specific patient populations. This creates nuisance alarms, which are due to alarm parameters being sensitive, but not specific. The distraction of nuisance alarms creates immunity to alarms that are most critical. Without clear defined protocols in place, the responsibility of alarm management falls to the bedside nurse. Unsafe actions such as ignoring alarms, silencing alarms, turning off alarms, and inappropriately adjusting alarms typically occurs (Stokowski, 2014). Many alarm management strategies have been recommended to decrease nuisance alarms and allow nurses to tailor alarm parameters. The first recommendation is daily electrode changes with proper skin preparation by elimination of hair from the application site, abrading the skin, cleaning with soap and water, and drying the skin completely (AACN, 2013). A study done on two adult acute care units utilized the above technique and decreased average alarms per bed per day by 46% (Cvah, Biggs, Rothwell, & Charles-Hudson, 2012). Second, nurses should customize alarm parameters on ECG monitors to meet the needs of the individual patient. This should be done within one hour of assuming care of the patient and/or with any change in patient status (AACN, 2013). A quality improvement
The purpose of the NPSG is to attract attention to alarm hazards and to focus on the development of a systematic approach to identifying solutions that have the most direct relationship to patient safety (“The Joint Commission announces,” 2013). The goal is outlined in two phases: Phase I requires hospitals to recognize alarms as an organizational priority and to isolate the most important alarms to be addressed. Phase II, which needs to be implemented by January 2016, requires organizations to have specific policy and procedures established that are directed towards solutions for alarm management (Sendelach, Wahl, Anthony, & Shotts, 2015; “The Joint Commission announces,” 2013). In addition, The ERCI Institute has identified alarm hazards on their Top 10 Health Technology Hazards since 2007 and recommends a thorough assessment of alarm management (ERCI Institute, 2013). This national awareness underscores the importance of aggressively addressing the complex issues surrounding alarm safety and promotes healthcare institutions to find solutions that mitigate the risk associated with the discordant mixture …show more content…
The institution uses default parameters that are set by the technology companies. These parameters are not tailored to specific patient populations. This creates nuisance alarms, which are due to alarm parameters being sensitive, but not specific. The distraction of nuisance alarms creates immunity to alarms that are most critical. Without clear defined protocols in place, the responsibility of alarm management falls to the bedside nurse. Unsafe actions such as ignoring alarms, silencing alarms, turning off alarms, and inappropriately adjusting alarms typically occurs (Stokowski, 2014). Many alarm management strategies have been recommended to decrease nuisance alarms and allow nurses to tailor alarm parameters. The first recommendation is daily electrode changes with proper skin preparation by elimination of hair from the application site, abrading the skin, cleaning with soap and water, and drying the skin completely (AACN, 2013). A study done on two adult acute care units utilized the above technique and decreased average alarms per bed per day by 46% (Cvah, Biggs, Rothwell, & Charles-Hudson, 2012). Second, nurses should customize alarm parameters on ECG monitors to meet the needs of the individual patient. This should be done within one hour of assuming care of the patient and/or with any change in patient status (AACN, 2013). A quality improvement