Recently, ECRI Institute released its Top Ten Technology Hazards for 2018. The purpose behind ECRI’s yearly list is to promote the safer use of technology:
The safe use of health technology—from beds and stretchers to large, complex imaging systems—requires identifying possible sources of danger or difficulty with those technologies and taking steps to minimize the likelihood that adverse events will occur. This list will help healthcare facilities do that.
Number 4 on this list deals with how Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems:
Secondary alarm notification systems are software solutions that send alarms and other relevant alerts from a medical device or IT system to a clinician’s smartphone or other communication device. The systems are intended to facilitate timely notification of the appropriate clinician, but configuration or management problems with the systems themselves can lead to alarm delivery delays or failures.
ECRI’s Top Ten Technology Hazards for 2018 describes how secondary notification systems may cause patient harm:
Delayed or failed delivery of a critical alarm or alert can lead to missed alarm conditions, delayed care, and avoidable patient harm.
Incidents that have been reported include:
- Alarm delivery delays and failures when a system became overloaded. The cause: Alarms were needlessly being broadcast to all users within a care unit.
- Dropouts and alarm delivery failures after installation of an antivirus software update. The cause: The update was incompatible with the secondary alarm notification system.
- Phones freezing or shutting down when the user switched between software applications. The cause: Conflicts between the secondary alarm notification system and other smartphone applications (e.g., text messaging, voice communications).
Maria Cvach, DNP, RN, CCRN (Director of Policy Management and Integration for Johns Hopkins Health System) and her colleagues in their paper, “Clinical Alarms and the Impact on Patient Safety” explain why notification systems are so important for the safety of patients:
Today most devices are manufactured with a functioning alarm. Alarms on acute care units are generated from any number of devices – infusion pumps, respiratory monitoring equipment, feeding pumps, bed or chair alarms, wound vacuum devices, sequential compression devices, cardiac monitors, ventilators, and patient call systems. However, there is no standardization of alarm sounds among manufacturers, so caregivers must be able to distinguish these audible alarms and react based on the perceived importance of the sound. It is ironic that the very alarms that are meant to protect patients have instead led to increased unit noise, alarm fatigue and a false sense of security regarding patient safety.
To help better understand secondary notification systems, the Physician-Patient Alliance will shortly be releasing a clinical education podcast, featuring an expert panel with
- Maria Cvach, DNP, RN, CCRN (Assistant Director of Nursing, Clinical Standards, The Johns Hopkins Hospital)
- Marc Schlessinger, RRT, MBA, FACHE (Senior Associate, ECRI Institute’s Applied Solutions Group)
- Leah Baron, MD (Chief, Department of Anesthesiology, Virtua Memorial Hospital).
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