The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid or nonactionable, and thus fail to respond or respond more slowly to actionable alerts. The article describes the progress made in reducing nonactionable alarms and making actionable alarms more useful to responding clinicians. Clinical approaches include customization of alert parameters to reduce nonactionable alarms, while engineering solutions include reducing the volume or adjusting the tone of auditory alerts.
Wolfe H, Wenger J, Sutton RM, et al. Pediatr Qual Saf. 2020;59:e319.
This article describes the use of “cold” debriefings performed more than one day after in-hospital cardiac arrest events at institutions participating in a pediatric resuscitation quality collaborative. Cold debriefings took place in one-third of events; the median time to debriefing was 26 days. The majority of comments arising from the debriefings involved clinical standards, cooperation and communication.
Hagedorn PA, Singh A, Luo B, et al. J Hosp Med. 2020;15:378-380.
Secure text messaging has emerged as one method to improve communication between providers and nurses. This paper discusses concerns over alarm fatigue, communication errors and omitting critical verbal communication and provides proposed solutions to support appropriate and effective use of text messaging in a healthcare setting.
Lake ET, Roberts KE, Agosto PD, et al. J Patient Saf. 2021;17:e1546-e1552.
The nursing work environment affects patient safety. This cross-sectional study surveyed nearly 2000 pediatric acute care nurses about their work environment and safety culture. Researchers measured the hospital work environment using a validated scale, and they assessed safety using the AHRQ Survey on Patient Safety Culture. A culture of blame and fear of speaking up remained prevalent among nurses participating in this survey. As with prior studies, investigators found an association between a high-functioning work environment and positive safety culture. The authors recommend enhancing pediatric acute care work environments for nurses in order to improve patient safety. A previous PSNet interview discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319:1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Crit Care Med. 2017;45:1481-1488.
These paired systematic reviews examined alert fatigue in the intensive care unit. The first systematic review found several strategies to reduce alerts including prioritizing alerts, developing multipart rules instead of simple alerts, and customizing commercial platforms with end-user input. The second systematic review found that alarm best practices from high reliability industries are not adhered to in intensive care unit settings.
Lake ET, de Cordova PB, Barton S, et al. Hosp Pediatr. 2017;7:378-384.
Missed nursing care is common and has been linked to adverse events. This survey found that more than half of pediatric intensive care unit nurses reported missing care during their prior shift. Higher patient loads and poor working environments were associated with more episodes of missed care, corroborating prior research.
Bedside monitors alert nurses to clinical deterioration. This prospective observational study examined nurse responses to bedside physiologic monitors. The mean response time was over 10 minutes. Less than 1% of alarms were actionable, underscoring the importance of addressing alarm fatigue.
Wolfe H, Zebuhr C, Topjian AA, et al. Crit Care Med. 2014;42:1688-95.
This single-center prospective study found that providing interdisciplinary post-event debriefs with quantitative feedback on chest compression depth, rate, and other indicators of high-quality cardiopulmonary resuscitation significantly improved cardiac arrest outcomes in a pediatric intensive care unit.
Paine CW, Goel V, Ely E, et al. J Hosp Med. 2016;11:136-144.
Alarm safety is now a Joint Commission National Patient Safety Goal. This systematic review analyzed 24 studies on alarm characteristics and 8 studies that evaluated interventions to improve alert fatigue. Consistent with other studies, the vast majority of the time, alarms do not signal problems that require clinician action. The most promising intervention strategies for reducing alarms that have emerged thus far are widening alarm parameters, implementing alarm delays, and frequently changing telemetry electrodes and wires. A PSNet perspective discussed approaches to reduce alert fatigue while maintaining safety.
Bonafide CP, Lin R, Zander M, et al. J Hosp Med. 2015;10:345-51.
Previous studies have documented high frequency of alarms for nurses in intensive care settings. This direct observation study of a pediatric intensive care unit found that response times increased when there were more preceding nonactionable alarms, demonstrating a delay in alarm response due to alarm fatigue. This finding underscores the importance of improving current alarm management.
Simpao AF, Ahumada LM, Desai BR, et al. J Am Med Inform Assoc. 2015;22:361-9.
Researchers used rapid-cycle iterative interventions to improve drug interaction alerts by eliminating clinically irrelevant notifications. These efforts resulted in fewer alerts and fewer manual overrides of alerts without any serious safety events, emphasizing the often cited need to streamline clinical decision support to prevent alarm fatigue.
Bonafide CP, Localio R, Song L, et al. Pediatrics. 2014;134:235-41.
Medical emergency teams (METs) have been widely implemented in hospitals, with some evidence suggesting that they may be effective at reducing serious clinical deteriorations. This study aimed to create a financial model to determine the potential benefits and costs of operating an MET at a children's hospital. Relying on various derived calculations, the authors estimate that the care of patients who experience a critical deterioration during hospitalization costs nearly $100,000 more following the event compared with other patients who transfer to an intensive care unit. The annual costs of operating an MET range widely, anywhere from $287,000 to $2.3 million, depending on who is staffed and whether the team has concurrent responsibilities or is freestanding. Under a bundled payment system—where a health system is paid a fixed reimbursement for a hospitalization—most MET team configurations would prove cost-effective if they successfully avoid a modest number of critical deteriorations each year. A prior AHRQ WebM&M perspective discusses early lessons of medical emergency teams.
Paciotti B, Roberts KE, Tibbetts KM, et al. Jt Comm J Qual Patient Saf. 2014;40:187-192.
In an effort to provide more timely responses to clinical deteriorations, some pediatric medical centers have enabled family members to directly activate medical emergency teams (METs). This study used semistructured interviews to examine physicians' viewpoints on issues related to family-activated METs. Even though the majority of physicians said they depend on families to identify subtle changes in their child's condition, 93% of respondents reported that families should not be able to access the MET directly. Some concerns included families' lack of medical knowledge and training to determine when a MET is necessary, and the belief that this responsibility could provide an undue burden and stress on family members. These tensions are similar to prior discussions about other efforts to engage patients in their own safety during hospitalization.
Bonafide CP, Localio R, Roberts KE, et al. JAMA Pediatr. 2014;168:25-33.
Despite conflicting evidence of their benefit, rapid response teams have been widely implemented in hospitals to address failure to rescue patients whose clinical status is worsening. This quasi-experimental study compared the trajectory of clinical deterioration among pediatric patients at an urban, tertiary care children's hospital before and after implementing a rapid response intervention. Over a 5-year period, the authors found that rapid response teams significantly improved the trajectory of clinical deterioration compared to the pre-intervention trajectory. They did not find statistically significant differences in rates of cardiac arrests or deaths. An accompanying editorial contends that measuring the trajectory of clinical deterioration does not adequately inform the effectiveness of rapid response systems.
Bonafide CP, Roberts KE, Priestley MA, et al. Pediatrics. 2012;129:e874-81.
This study developed the critical deterioration metric to complement existing strategies that evaluate rapid response team performance. The proposed metric is a rate defined as the number of patients transferred to the intensive care unit (ICU) and requiring life-sustaining interventions within 12 hours per 1000 non-ICU patient days.
Metlay JP, Hennessy S, Localio R, et al. J Gen Intern Med. 2008;23:1589-94.
Patients who received specific instructions (from physicians, nurses, or pharmacists) when prescribed the anticoagulant warfarin experienced fewer hospitalizations due to bleeding complications. The Agency for Healthcare Research and Quality (AHRQ) has published a patient information guide for warfarin therapy.
Koppel R, Leonard CE, Localio R, et al. J Am Med Inform Assoc. 2008;15:461-5.
Accurate identification of medication errors poses methodological challenges. This study analyzed orders entered and discontinued within 2 hours as a trigger for inexpensive and rapid real-time evaluation. Investigators discovered that two thirds of orders discontinued within 45 minutes were viewed as inappropriate.