The Problem of Alarm Fatigue
Introduction:
Enter any emergency room or hospital floor, and you will most likely find yourself accompanied with the sounds of beeps, chimes, and dings. Sounds are from the multitude of medical monitors and equipment being used to protect and keep patients alive. Alarms can be categorized as either physiological or technical. Physiological alarms are caused by a vital sign or patient conditions which has been deemed abnormal by the equipment or hospital. Technical alarms occur when there is something on the equipment that needs attention such as a defective part or a low battery.
Though both physiological and technical issues are important situations that need to be alerted to medical staff, many times the issues are not real or important issues collectively known as false alarms. A clinician must still attend each alert. False alarms place extra stress on medical professionals and take attention away from other issues. The more false alarms are triggered, the less the medical staff will believe the medical equipment. This leads to alarm fatigue, where alarms may start to be ignored leading to poor patient care. This paper will investigate the causes and prevalence of false alarms and . Many studies of alarm fatigue have described the affects false alarms, in a hospital and what they have done to decrease the number of false alarms. However the number of false alarms can be improved by the medical device industry, medical device regulatory groups, as well as in the hospitals. Literature Review: Medical equipment contains alarms to alert clinicians when a hazardous situation occurs. Medical equipment is designed with high sensitivity thresholds in order to ensure that every possible negative occurrence is alerted. However, medical equipment is notorious for having a low specificity, alarming when there is not a medical emergency occurring, causing a larger number of false positives. These false positive alarms can be draining on nurses and other medical staff. The results of this stress cause alarm fatigue where alarms are missed, ignored, or not responded to with the amount of urgency they require. In one hospital situation a soft alarm sounded for 75 minutes, indicating that the medical equipment was running out of battery. The alarm was ignored, and eventually the medical monitor could no longer function and turned off. While the monitor was off, the patient experienced cardiac arrest and passed away. Since the monitor was not functioning, the medical staff did not here any alarms indicating that the patient was in need of medical attention. (Sendelbach & Funk, 2013) Unfortunately, the story of this hospital is not an isolated case. The U.S. Food and Drug Administration (FDA) keeps a database of reports made by manufacturers, importers, users and consumers on medical devices. Five hundred and sixty-six reports of patient deaths related to monitoring device alarms were reported between 2005 and 2008 (Cvach, 2012). Hospitals realize the hazards of alarm systems. Each year the ECRI Institute, a non-profit organization dedicated to improving patient care, makes creates a “Top 10 Health Technology Hazards Report”. For the past seven years ECRI has ranked Alarm hazards as one of the top two hazards as shown in Table 1. Table 1 Top Medical Technology Hazards as ranked by the Emergency Care Research Institute ECRI Ranked Hazards Year Number 1 Number 2 Source 2010 Cross-Contamination from Flexible Endoscopes Alarm Hazards (Marion, 2009) 2011 Radiation overdose and other does errors during radiation Alarm …show more content…
They have taken steps to improve the performance of medical equipment. Hospitals have seen reductions in their number of false positives by implementing better medical practices including daily ECG electrode changes, properly preparing the skin for monitoring, and customizing alarm parameter limits (Sendelbach & Funk, 2013). The FDA creates documents with requirements and recommendations for medical equipment in the United States. One attempt that was made with the intention of improving alarm recognition was a standardization of medical alarm sounds. These sounds should reflect the patient’s condition, as shown in Table 2 (ISO, 2006). However this has not found to be completely successful as one study found that only 38% of experienced nurses were able to differentiate the different alarm sounds (Cropp, Woods, & Bredle,
Introduction:
Enter any emergency room or hospital floor, and you will most likely find yourself accompanied with the sounds of beeps, chimes, and dings. Sounds are from the multitude of medical monitors and equipment being used to protect and keep patients alive. Alarms can be categorized as either physiological or technical. Physiological alarms are caused by a vital sign or patient conditions which has been deemed abnormal by the equipment or hospital. Technical alarms occur when there is something on the equipment that needs attention such as a defective part or a low battery.
Though both physiological and technical issues are important situations that need to be alerted to medical staff, many times the issues are not real or important issues collectively known as false alarms. A clinician must still attend each alert. False alarms place extra stress on medical professionals and take attention away from other issues. The more false alarms are triggered, the less the medical staff will believe the medical equipment. This leads to alarm fatigue, where alarms may start to be ignored leading to poor patient care. This paper will investigate the causes and prevalence of false alarms and . Many studies of alarm fatigue have described the affects false alarms, in a hospital and what they have done to decrease the number of false alarms. However the number of false alarms can be improved by the medical device industry, medical device regulatory groups, as well as in the hospitals. Literature Review: Medical equipment contains alarms to alert clinicians when a hazardous situation occurs. Medical equipment is designed with high sensitivity thresholds in order to ensure that every possible negative occurrence is alerted. However, medical equipment is notorious for having a low specificity, alarming when there is not a medical emergency occurring, causing a larger number of false positives. These false positive alarms can be draining on nurses and other medical staff. The results of this stress cause alarm fatigue where alarms are missed, ignored, or not responded to with the amount of urgency they require. In one hospital situation a soft alarm sounded for 75 minutes, indicating that the medical equipment was running out of battery. The alarm was ignored, and eventually the medical monitor could no longer function and turned off. While the monitor was off, the patient experienced cardiac arrest and passed away. Since the monitor was not functioning, the medical staff did not here any alarms indicating that the patient was in need of medical attention. (Sendelbach & Funk, 2013) Unfortunately, the story of this hospital is not an isolated case. The U.S. Food and Drug Administration (FDA) keeps a database of reports made by manufacturers, importers, users and consumers on medical devices. Five hundred and sixty-six reports of patient deaths related to monitoring device alarms were reported between 2005 and 2008 (Cvach, 2012). Hospitals realize the hazards of alarm systems. Each year the ECRI Institute, a non-profit organization dedicated to improving patient care, makes creates a “Top 10 Health Technology Hazards Report”. For the past seven years ECRI has ranked Alarm hazards as one of the top two hazards as shown in Table 1. Table 1 Top Medical Technology Hazards as ranked by the Emergency Care Research Institute ECRI Ranked Hazards Year Number 1 Number 2 Source 2010 Cross-Contamination from Flexible Endoscopes Alarm Hazards (Marion, 2009) 2011 Radiation overdose and other does errors during radiation Alarm …show more content…
They have taken steps to improve the performance of medical equipment. Hospitals have seen reductions in their number of false positives by implementing better medical practices including daily ECG electrode changes, properly preparing the skin for monitoring, and customizing alarm parameter limits (Sendelbach & Funk, 2013). The FDA creates documents with requirements and recommendations for medical equipment in the United States. One attempt that was made with the intention of improving alarm recognition was a standardization of medical alarm sounds. These sounds should reflect the patient’s condition, as shown in Table 2 (ISO, 2006). However this has not found to be completely successful as one study found that only 38% of experienced nurses were able to differentiate the different alarm sounds (Cropp, Woods, & Bredle,