Patient Safety Week

Sounding the Alarm on a Significant Patient Safety Concern

Anyone who has spent any time in a hospital knows that it is anything but quiet. But most of the beeps and buzzes are there to signal staff when something is not right with one of their patients. As confident as we should feel that these alarms will protect patients from harm, this constant barrage of sounds may contribute to preventable injuries and deaths in hospitals and long-term care facilities. Identified as one of 10 top patient safety issues for 2014, alarm fatigue has the potential to cause serious potentially fatal harm to patients.

Alarm fatigue occurs when medical staff becomes desensitized to the alarms they hear all day. It’s not an overestimation to say that hospital staff can be exposed to hundreds of alarms during their shifts, many of which do not signal an emergency. As a result, they begin to more slowly respond because they do not believe that the current alarm is connected to a patient experiencing an emergency situation. This reaction is often because some alarms can be sensitive enough to go off when a patient simply moves or coughs.

The number of patients harmed by alarm fatigue can be staggering but the currently reported numbers do not tell the whole story. Between January 2009 and June 2012, The Joint Commission received 80 reports of alarm-related deaths and 13 serious alarm-related injuries. Hospitals voluntarily report incidents so these numbers a likely much higher as events go underreported.

Alarm fatigue has been identified as a patient safety concern for several years. The ECRI Institute called it one of the biggest technology hazards in 2013. The Joint Commission and the FDA are working jointly to find a solution to this problem. The Joint Commission issued a “sentinel event alert” to hospitals to warn of alarm fatigue and how it could jeopardize patients; it also named the issue a National Patient Safety Goal, requiring facilities accredited by the Joint Commission to improve their systems to reduce the number of alarms. The FDA will survey about 4,500 hospitals and 1,000 long-term care facilities to gain better understanding of what facilities needs to do to improve practices in order to provide recommendations.

The first phase of the Joint Commission’s National Patient Safety Goal went into effect at the beginning of the year and will heighten awareness of the potential risks associated with alarm fatigue. The second phase, which introduces requirements to mitigate those risks, will go into effect on January 1, 2016. The Joint Commission provides several recommendations hospitals can use to reduce the number alarms and reduce the likelihood of alarm fatigue among staff. These include identifying all alarm-equipped medical equipment and deciding how they should be set and determine what alarm signals are clinically necessary to reduce the number of nuisance alarms. They also recommend proper training on safe alarm management and response in high-risk areas of the hospital.

During patient safety week it is important to remember that we must remain diligent in our efforts to ensure the safety of patients, and this includes keeping our eyes–and ears–open to warnings. Take some time to see what strategies your health care facility is adopting to improve patient safety and reduce alarm fatigue.

Original post.

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