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Search results for "Hospitals"

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Web Resource > Multi-use Website

National Coalition for Alarm Management Safety.

Healthcare Technology Safety Institute and Association for the Advancement of Medical Instrumentation.

Alarm fatigue has been recognized as a contributor to serious errors in hospitals. This Web site provides a way for hospitals, industry representatives, regulators, and professional societies to compile resources and discuss strategies to reduce unnecessary alarms.

Journal Article > Study

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

Bonafide CP, Localio AR, Holmes JH, et al. JAMA Pediatr. 2017 Apr 10; [Epub ahead of print].

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.

Newspaper/Magazine Article

How redesigning the abrasive alarms of hospital soundscapes can save lives.

Couch C. Fast Company. April 3, 2017.

Alarm frequency can contribute to distractions and stress in the hospital environment. Reporting on alarm fatigue as a safety issue, this magazine article describes innovative strategies to manage noise in the hospital environment such as sound design and customizing alarms.

Journal Article > Study

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

Allan SH, Doyle PA, Sapirstein A, Cvach M. Jt Comm J Qual Patient Saf. 2017;43:62-70.

Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.

Journal Article > Commentary

Alarm fatigue: use of an evidence-based alarm management strategy.

Turmell JW, Coke L, Catinella R, Hosford T, Majeski A. J Nurs Care Qual. 2017;32:47-54.

Reducing nuisance alarms can address alarm fatigue and improve the safety of care. This commentary describes how one hospital utilized the Plan-Do-Study-Act model to design and implement an alarm monitoring strategy to decrease alarms and unnecessary continuous cardiac monitoring over a 2-year period. The authors summarize the results of the project and lessons learned.

Journal Article > Review

Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor.

Simpson KR, Lyndon A, Davidson LA. Nurs Womens Health. 2016;20:358-366.

Labor and delivery care is considered high risk for sentinel events should something go wrong. This review discusses how audible surveillance in this setting can contribute to alert fatigue and distraction among nurses and raises concerns that no standards exist to improve the effectiveness of electronic fetal monitoring.

Newspaper/Magazine Article

Screen flashes and pop-up reminders: 'alert fatigue' spreads through medicine.

Luthra S. Kaiser Health News. June 15, 2016.

Alert fatigue is known to contribute to medical error. This news article reports on the problem of clinically irrelevant alarms overwhelming clinicians and what hospitals and health information technology vendors are doing to decrease them. Strategies include applying human factors engineering concepts to alert triggers and designing spaces to reduce alarm-associated interruptions and fatigue.

Perspectives on Safety > Interview

In Conversation With... Barbara Drew, RN, PhD

Alert and Alarm Fatigue, May 2016

Dr. Drew is the David Mortara Distinguished Professor of Physiological Nursing and Clinical Professor of Medicine in Cardiology at the University of California, San Francisco. We spoke with her about the perils and prevalence of alert fatigue.

Perspectives on Safety > Perspective

Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue

with commentary by Samantha Jacques, PhD, and Eric Williams, MD, MS, MMM, Alert and Alarm Fatigue, May 2016

This piece describes strategies to reduce alarm fatigue in hospitals, including educating staff and patients, customizing alarm settings, and performing maintenance of lead wires.

Journal Article > Study

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

Her QL, Amato MG, Seger DL, et al. J Am Med Inform Assoc. 2016;23:924-933.

Users often bypass alerts meant to enhance the safety of medication ordering and dispensing technologies. This observational study at a large academic medical center found approximately one in five nonformulary medication alerts are inappropriately overridden. The authors suggest strategies that future research should examine for improving the design of nonformulary alerts.

Newspaper/Magazine Article

At the hospital, better responses to those beeping alarms.

Landro L. Wall Street Journal. January 4, 2016.

Alert fatigue is a well-known problem in hospitals. This newspaper article reports on efforts to reduce unnecessary alarms in hospitals to prevent staff from overlooking critical alerts. Highlighting strategies such as using secondary notification systems and recalibrating alerts according to the severity of physiologic change, the article also describes organizational guidelines to improve alarm safety. A recent WebM&M commentary explored how alarm fatigue can result in patient harm.

Journal Article > Study

Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project.

Sowan AK, Gomez TM, Tarriela AF, Reed CC, Paper BM. JMIR Hum Factors. 2016;3:e1.

In 2014, The Joint Commission added improving the safety of alarm systems as a National Patient Safety Goal. This study describes a quality improvement project to implement a change in default alarm settings and provide nursing education in a 20-bed transplant and cardiac intensive care unit. Although the alarm rate per patient day decreased from approximately 88 to 59 alerts, nursing attitudes toward alarms and maintaining best clinical practices did not change.

Journal Article > Review

Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.

  • Classic

Paine CW, Goel VV, 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. 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.

Journal Article > Review

Alarm fatigue: impacts on patient safety.

Ruskin KJ, Hueske-Kraus D. Curr Opin Anaesthesiol. 2015;28:685-690.

Alarm fatigue is a recognized safety concern in health care. Exploring factors that contribute to alarm fatigue, this review outlines technical, organizational, and educational approaches to managing its effect on care safety. A recent WebM&M commentary provides an overview of alarm fatigue and describes ways to enhance alarm safety.

Journal Article > Study

Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.

  • Classic

Lacson R, O'Connor SD, Sahni VA, et al. BMJ Qual Saf. 2016;25:518-524.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Journal Article > Study

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.

Dekarske BM, Zimmerman CR, Chang R, Grant PJ, Chaffee BW. Int J Med Inform. 2015;84:1085-1093.

Alert fatigue is the Achilles heel of medication ordering with computerized physician order entry. This randomized controlled trial found that the appropriateness of alert overrides increased with implementation of a customized list of alert override reasons, compared with default options, in a CPOE system. This demonstrates the need to develop more clinically relevant reasons for overriding alerts in order to enhance the safety of medication prescribing.

Newspaper/Magazine Article

Raising an alarm, doctors fight to yank hospital ICUs into the modern era.

McFarling UL. STAT. September 7, 2016.

Intensive care units (ICUs) are complex environments that harbor various challenges to safe care delivery. Reporting on alarm fatigue and insufficient interoperability between devices in ICUs, this news article describes solutions to address data overload and highlights the efforts of several hospitals working toward developing ICUs that are more respectful of patients and the clinical teams caring for them.

Journal Article > Study

Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry.

Idemoto LM, Williams BL, Ching JM, Blackmore CC. Am J Health Syst Pharm. 2015;72:1481-1488.

This study examined the effect of a custom alert intended to reduce medication-timing errors associated with introduction of computerized provider order entry, which can lead to too-frequent or missed doses of medications. Using a rigorous interrupted time-series design, researchers found fewer medication-timing errors after implementation of this alert. This work demonstrates how custom alerts developed by clinicians can harness the electronic health record to improve safety.

Newspaper/Magazine Article

Stop the noise: a quality improvement project to decrease electrocardiographic nuisance alarms.

Sendelbach S, Wahl S, Anthony A, Shotts P. Crit Care Nurse. 2015;35:15-22.

Alert fatigue has been highlighted as a contributor to patient harm, but research examining interventions to improve alarm safety has been limited. This article describes an intervention that used baseline data and rapid process improvement design to reduce electrocardiographic and pulse oximetry alarms in a cardiovascular care unit.

Journal Article > Commentary

Making healthcare safer by understanding, designing and buying better IT.

Thimbleby H, Lewis A, Williams J. Clin Med. 2015;15:258-262.

Design weaknesses for medical devices can remain unrecognized due to insufficient reporting and the tendency to place blame on the user rather than question whether the equipment functioned appropriately. Discussing flaws in health IT design and how they can contribute to patient harm, this commentary advocates for enhanced reporting of device-related incidents to raise awareness about risks and enable learning from errors.

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