By Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant)
17-year old Mariah Edwards went in for a procedure that is performed countless times each year – a tonsillectomy. Recovering after the successful and very routine procedure, she was administered a dose of fentanyl to manage her pain. Although she was monitored continuously electronically, one of the attending nurses admitted on discovery that the monitor was muted for sound.
The settlement: $6 million. But, what really is $6 million to the parents of Mariah Edwards who have lost a child? What is the emotional toll to her nurses and other caregivers?
Healthcare professionals and hospital staff who a habit or even unintentially disconnect monitoring equipment of silence alarms are vulnerable for missing important safety signals from a patient that is detecting potential harm. It should be a well-established clinical fact that continuous monitoring equipment generate visual and audible alarm signals to alert clinicians for potential changes in their patient’s condition that may require immediate urgent attention. The nature and purpose for ordering and maintaining continuous monitoring are to have a system that provides clinicians with essential information necessary to properly evaluate the patient and make appropriate treatment decisions.
Unfortunately, it has become a well known fact that hospital nationwide are struggling with major safety issues related to alarms and continuous monitoring systems despite the fact that these systems are monitoring key and vital changes in a patient’s physiologic condition. Patient deaths have been mounting at a significant rate due to the syndrome now entitled as “alarm fatigue”. One of the key causes of patient deaths are stemming from “human error” with secondary factors including equipment failure. Human error is really a term for failure to recognize and make a detrimental treatment decision not based on physiologic warnings or precursors of adverse events – such as turning off the volume on a monitor.
The Joint Commission has progressively been monitoring this issue of clinical alarms which has become a serious situation that requires immediate remedial attention. The Joint Commission has had to progressively develop new National Patient Safety Goals which target and address clinical alarm systems. This new NPSG is effective January 1, 2014 and targets the development of an Alarm Management Program that is articulated, developed by stake holders and implemented as well as continually evaluated for performance improvement initiatives.
The ECRI Institute, since 2008, has initiated a top Ten Health Technology Hazard list and alarms have consistently been at the top of the list. Currently alarms have been elevated to being first on this hazard list due to the criteria of prevalence of the problem as well as severity, deemed “high profile” and whether there are potential solutions for improvement. Alarm hazards score high on the above criteria which means alarm safety should be at an all time high priority for patient safety initiatives in all hospitals.
High volume risk points contribute to alarm and monitoring adverse events including the phenomena called “alarm fatigue”, communication errors, including breakdowns and barriers, consistent training issues/competencies and lastly equipment failure. It has been documented that alarm fatigue is one of the most common contributors to alarm failures and patient harm. Staff working in high volume alarm areas often becomes neutral or desensitized to the number of alarms which results in delayed response error deterrent or poor judgment and missed alarms. All of these factors contribute to an escalation of patient adverse events resulting in harm and adversely effecting the promotion of a safe care environment.
The need for the development of evidenced based criteria for alarm safety, and prevention of alarm fatigue and failure to respond, is increasingly important consideration that can no longer be ignored. A key answer would be the development of a multidisciplinary team with stakeholders that have vested interest in reviewing trends and developing critical thinking clinical protocols/role expectations when taking care of continuously monitored patients.
The goal of the developed protocols should clearly identify:
- Who is responsible for alarm notification and response.
- Appropriate hands off communication.
- Trending, analyzing , and measuring, in real time, all potential alarm related problems including “near misses”.
- Building the culture of safety and having upper management that have the “buy-in” to maximize the safety movement within their respective institutions.
- Defining the criteria and decision tree for continuously monitoring a patient when using opioids.
Utilizing the above approach takes a committed quality investment whose patient safety rewards should be clearly acknowledged with periodic review and revision of alarm protocols based on current peer reviewed publications and internal trending data. The investment is well worth the challenge to get to this critical point and requires perseverance to maintain maximum alarm safety.
It isn’t enough to have a monitor, somebody has to monitor the monitors. When we look at old monitors, being retired, the mute button is almost always noticeably more worn down than any other button. All patients , like Mariah, should be electronically monitored. But what good is it if nobody monitors the monitor? It’s like waiting and wondering why your food isn’t cooking, and the oven isn’t turned on. Just having an oven isn’t enough to make a cake. Just having a monitor isn’t enough to keep our patients safe