Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 2
Human Factors Engineering
- Medical Alarm Design
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Specialization of Care 3
- Technologic Approaches 8
- Alert fatigue 1
- Device-related Complications 6
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 6
- Surgical Complications 2
- Family Members and Caregivers 1
- Health Care Executives and Administrators 16
Health Care Providers
- Nurses 5
Non-Health Care Professionals
- Engineers 12
- Patients 11
Search results for "Medical Alarm Design"
- Newspaper/Magazine Article
- Medical Alarm Design
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Smart pumps offer both benefits and drawbacks that can affect medication safety. This newsletter article explores missteps related to lack of compliance with setting hard stops to protect patients when using unique intravenous medication concentrations. Recommendations to prevent errors include using standardized dosing concentrations as often as possible, adhering to metric unit dosing requirements, and verifying pump programming settings.
Couch C. Fast Company. April 3, 2017.
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.
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.
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.
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
The disabling of alerts due to alarm fatigue can hinder the ability of a health information system to warn prescribers and pharmacists of potentially harmful drug–disease combinations. This newsletter article describes an incident in which a patient died when health information technology systems failed to alert the physician and pharmacist regarding a drug–disease interaction. Recommendations to avoid risks include evaluating drug information databases, adding comorbid conditions into electronic health records, and reducing provider overreliance on alerts.
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
High-alert medications have the potential to cause serious patient harm. This article focuses on four primary types of high-alert medications—anticoagulants, sedatives, insulins, and opioids—that can have serious adverse effects and recommends strategies to reduce risks, including conducting independent double-checks and decreasing interruptions.
24-Hour inpatient pulse oximetry monitoring reduces rescue events and intensive care unit transfers.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Effective monitoring can enable early detection of deteriorating patients while reducing nuisance alarms. Relating how one hospital implemented round-the-clock monitoring and adjusted alarm thresholds, this article reports results of the program such as fewer patient transfers to the intensive care unit and no subsequent adverse events.
Addis LM, Cadet VN, Graham KC. Patient Saf Qual Healthc. May/June 2014.
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.
Welch J. Patient Saf Qual Healthc. May/June 2012;9:26-29,32-33.
Gee T, Moorman BA. Patient Saf Qual Healthc. March/April 2011;8:14-17.
Highlighting dangers presented by alarm fatigue, modification, and miscommunication, this article discusses strategies to reduce such incidents.
Kowalczyk L. Boston Globe. February 13–14, 2011.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
Kowalczyk L. Boston Globe. February 21, 2010.
This news account discusses a patient death after a heart monitor alarm was inadvertently turned off. Hospital and device safety experts weigh in on strategies to prevent these types of errors.
ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.
This article provides screening, dosing, and monitoring recommendations for using basal opioid infusions and patient-controlled analgesia (PCA) in patients at risk for developing respiratory depression.
Fabregas L. Pittsburgh Tribune-Review. May 19, 2006.
This article reports on a system implemented at two hospitals that allows patients or families to initiate a "code" when a patient's condition raises serious concerns.
ISMP Medication Safety Alert! Acute Care Edition. August 25, 2005;10:1-3.
The Institute for Safe Medication Practices (ISMP) reports on a 2005 field test that indicates many pharmacy computer systems are unable to detect potential errors. The results show no improvement in such systems since the last field test in 1999.
Rogoski RR. Health Manage Technol. August 2005;26:12,14,16,18.
This article reports on two efforts to reduce medical errors through information technology implementation.
Olson J. Star Tribune. February 9, 2015.