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The machines measure every vital sign, every drip of fluid, every drop excreted. Each has an associated noise “informing” us that the event has occurred at the appropriate time. The never-ending chimes, bells, and buzzers echo throughout the halls of hospitals where patients are supposed to be resting and recovering. As each machine announces the patients’ progress, the cacophony increases and violates the healing environment, creating anxiety for both the patients and the nursing staff.
Anyone who has spent a night in the hospital, either as a patient or at the bedside of a loved one, knows all those sounds are disturbing. They interfere with sleep, interrupt calming positive thoughts of healing, and cause worry about what is happening to other patients or what the noise from one’s own machine means.
Years ago, there were signs in the hospital reminding us “the patient must have absolute quiet.” Even then we knew, perhaps only tacitly, that undisturbed sleep of adequate duration is required to recover from illness or surgery (patients) or maintain our performance and health (hospital staff).
More recently, research has shown that the most powerful disruptors of sleep are automatic noises designed, intentionally, to alert, even when the signaling devices are on a quiet setting.1,2 The hospital, once considered a quiet zone, is now a chaotic riot of distracting noise. Clearly, one would not describe this scenario as conducive to healing.
Alarm systems, designed to alert caregivers to potential problems with a patient, have increased over time—and with them, the noise level. There are now so many different alarms that we have become inured to them. This desensitization, known as alarm fatigue, can lead to inappropriate responses to the alarms. In some cases, this has included decreasing the alarm volume, disabling the alarm, or setting the alarm beyond safety limits.3
As a result, the problem is far more serious than the distraction or disruption the noises cause. Between 2005 and 2008, the FDA received 566 reports of patient deaths related to the alarms on monitoring devices.4 In one case highlighted by the agency, an infant died when staff overlooked the visual cues on its heart rate monitor; it turned out that the audible alarm notification had not been set up. In another, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor issuing an alert. Although the monitor had detected the problem, its dysrhythmia processing had been turned off.
The FDA and the Association for the Advancement of Medical Instrumentation jointly convened a summit to investigate this disconcerting issue in October 2011. They recognized a window of opportunity to place the hazards and frustrations of alarm fatigue on the safety agenda. The committee emphasized the need to keep the focus on patient safety first and foremost, as this will provide a sense of urgency to the issue, and outlined an ambitious goal that by 2017, “no patient will be harmed by adverse alarm events.”5
So what exactly is alarm fatigue? Continue reading to find out...
So what exactly is alarm fatigue? There is not yet a standard definition, but summit participants offered a variety of interpretations and examples. Many of them describe the consequences of alarm fatigue, such as:
• A nurse or other caregiver being overwhelmed with 350 alarm conditions per patient per day.
• Patients’ inability to rest with the multitude of alarms sounding in the room.
• A true life-threatening event lost amid the noise of multiple devices with competing signals—often leaving staff uncertain of which to address first or how to respond.
They also noted that technology is driving process, rather than the other way around.5
Recently, Wong, Mabuyi, and Gonzalez3 found that more than 95% of hospitals are concerned about alarm fatigue. That concern has now extended beyond individual hospitals and gained the attention of The Joint Commission (TJC). Following reports of 80 alarm-related deaths that occurred between January 2009 and June 2012, TJC issued a Sentinel Event Alert6 in April 2013, addressing medical device alarm safety in hospitals. The commission noted that “these devices present a multitude of challenges ... for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.”
Taking the quest for a solution a step further, in June 2013, TJC approved a new National Patient Safety Goal (NPSG) on clinical alarm safety for hospitals.7 The NPSG, which took effect in January 2014, requires that hospitals initiate improvements to ensure alarms on medical equipment are heard and responded to in a timely fashion.7
Implementation of this NPSG will occur in two phases. In Phase I (which started in January 2014), administrators will be required to “establish alarm system safety as a hospital priority” and identify the most important signals to manage based on their own internal situations (including an assessment of the risk to the patient if the alarm is ignored and whether the alarm unnecessarily contributes to the noise level). In Phase II (commencing January 2016), hospitals will be expected to develop and implement specific policies and procedures, including clinically appropriate settings for alarms and who has the authority to change the settings or set parameters to “off.” Education on alarm system management will also be required for all those in the organization who may interact with the monitoring equipment.7
We must find ways to minimize the noise and stress, for our sakes as well as our patients’—but we must do so without sacrificing safety. How do you see this playing out? Share your thoughts and ideas with me at [email protected].
Personally, I can see it now: A hospital with all the technology of the future, but without the “bells and whistles.” Finally, peace and quiet!
Continue for the references...
REFERENCES
1. Solet JM, Buxton OM, Ellenbogen JM, et al. Evidence-based Design Meets Evidence-based Medicine: the Sound Sleep Study. Concord, CA: The Center for Health Design; 2010.
2. Ellenbogen JM, Buxton OM, Wang W, et al. Sleep disruption due to hospital noises. In: Griefahn B, ed. 10th International Congress on Noise as a Public Health Problem 2011. Vol 2. London, UK: Institute of Acoustics; 2011: 618-626.
3. Wong M, Mabuyi A, Gonzalez B; Physician-Patient Alliance for Health & Safety. First National Survey of Patient-Controlled Analgesia Practices (2013). http://ppahs.files.wordpress.com/2013/10/ppahs-sasm-hand out.pdf. Accessed February 18, 2014.
4. FDA. Alarming Monitor Problems [podcast]. FDA Patient Safety News. Show #106; January 2011.
5. Association for the Advancement of Medical Instrumentation. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit (2011). www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf. Accessed February 18, 2014.
6. The Joint Commission. Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013. www.jointcommission.org/sea_issue_50. Accessed February 18, 2014.
7. The Joint Commission. National Patient Safety Goal on Alarm Management. NPSG.06.01.01. www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf. Accessed February 18, 2014.
The machines measure every vital sign, every drip of fluid, every drop excreted. Each has an associated noise “informing” us that the event has occurred at the appropriate time. The never-ending chimes, bells, and buzzers echo throughout the halls of hospitals where patients are supposed to be resting and recovering. As each machine announces the patients’ progress, the cacophony increases and violates the healing environment, creating anxiety for both the patients and the nursing staff.
Anyone who has spent a night in the hospital, either as a patient or at the bedside of a loved one, knows all those sounds are disturbing. They interfere with sleep, interrupt calming positive thoughts of healing, and cause worry about what is happening to other patients or what the noise from one’s own machine means.
Years ago, there were signs in the hospital reminding us “the patient must have absolute quiet.” Even then we knew, perhaps only tacitly, that undisturbed sleep of adequate duration is required to recover from illness or surgery (patients) or maintain our performance and health (hospital staff).
More recently, research has shown that the most powerful disruptors of sleep are automatic noises designed, intentionally, to alert, even when the signaling devices are on a quiet setting.1,2 The hospital, once considered a quiet zone, is now a chaotic riot of distracting noise. Clearly, one would not describe this scenario as conducive to healing.
Alarm systems, designed to alert caregivers to potential problems with a patient, have increased over time—and with them, the noise level. There are now so many different alarms that we have become inured to them. This desensitization, known as alarm fatigue, can lead to inappropriate responses to the alarms. In some cases, this has included decreasing the alarm volume, disabling the alarm, or setting the alarm beyond safety limits.3
As a result, the problem is far more serious than the distraction or disruption the noises cause. Between 2005 and 2008, the FDA received 566 reports of patient deaths related to the alarms on monitoring devices.4 In one case highlighted by the agency, an infant died when staff overlooked the visual cues on its heart rate monitor; it turned out that the audible alarm notification had not been set up. In another, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor issuing an alert. Although the monitor had detected the problem, its dysrhythmia processing had been turned off.
The FDA and the Association for the Advancement of Medical Instrumentation jointly convened a summit to investigate this disconcerting issue in October 2011. They recognized a window of opportunity to place the hazards and frustrations of alarm fatigue on the safety agenda. The committee emphasized the need to keep the focus on patient safety first and foremost, as this will provide a sense of urgency to the issue, and outlined an ambitious goal that by 2017, “no patient will be harmed by adverse alarm events.”5
So what exactly is alarm fatigue? Continue reading to find out...
So what exactly is alarm fatigue? There is not yet a standard definition, but summit participants offered a variety of interpretations and examples. Many of them describe the consequences of alarm fatigue, such as:
• A nurse or other caregiver being overwhelmed with 350 alarm conditions per patient per day.
• Patients’ inability to rest with the multitude of alarms sounding in the room.
• A true life-threatening event lost amid the noise of multiple devices with competing signals—often leaving staff uncertain of which to address first or how to respond.
They also noted that technology is driving process, rather than the other way around.5
Recently, Wong, Mabuyi, and Gonzalez3 found that more than 95% of hospitals are concerned about alarm fatigue. That concern has now extended beyond individual hospitals and gained the attention of The Joint Commission (TJC). Following reports of 80 alarm-related deaths that occurred between January 2009 and June 2012, TJC issued a Sentinel Event Alert6 in April 2013, addressing medical device alarm safety in hospitals. The commission noted that “these devices present a multitude of challenges ... for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.”
Taking the quest for a solution a step further, in June 2013, TJC approved a new National Patient Safety Goal (NPSG) on clinical alarm safety for hospitals.7 The NPSG, which took effect in January 2014, requires that hospitals initiate improvements to ensure alarms on medical equipment are heard and responded to in a timely fashion.7
Implementation of this NPSG will occur in two phases. In Phase I (which started in January 2014), administrators will be required to “establish alarm system safety as a hospital priority” and identify the most important signals to manage based on their own internal situations (including an assessment of the risk to the patient if the alarm is ignored and whether the alarm unnecessarily contributes to the noise level). In Phase II (commencing January 2016), hospitals will be expected to develop and implement specific policies and procedures, including clinically appropriate settings for alarms and who has the authority to change the settings or set parameters to “off.” Education on alarm system management will also be required for all those in the organization who may interact with the monitoring equipment.7
We must find ways to minimize the noise and stress, for our sakes as well as our patients’—but we must do so without sacrificing safety. How do you see this playing out? Share your thoughts and ideas with me at [email protected].
Personally, I can see it now: A hospital with all the technology of the future, but without the “bells and whistles.” Finally, peace and quiet!
Continue for the references...
REFERENCES
1. Solet JM, Buxton OM, Ellenbogen JM, et al. Evidence-based Design Meets Evidence-based Medicine: the Sound Sleep Study. Concord, CA: The Center for Health Design; 2010.
2. Ellenbogen JM, Buxton OM, Wang W, et al. Sleep disruption due to hospital noises. In: Griefahn B, ed. 10th International Congress on Noise as a Public Health Problem 2011. Vol 2. London, UK: Institute of Acoustics; 2011: 618-626.
3. Wong M, Mabuyi A, Gonzalez B; Physician-Patient Alliance for Health & Safety. First National Survey of Patient-Controlled Analgesia Practices (2013). http://ppahs.files.wordpress.com/2013/10/ppahs-sasm-hand out.pdf. Accessed February 18, 2014.
4. FDA. Alarming Monitor Problems [podcast]. FDA Patient Safety News. Show #106; January 2011.
5. Association for the Advancement of Medical Instrumentation. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit (2011). www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf. Accessed February 18, 2014.
6. The Joint Commission. Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013. www.jointcommission.org/sea_issue_50. Accessed February 18, 2014.
7. The Joint Commission. National Patient Safety Goal on Alarm Management. NPSG.06.01.01. www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf. Accessed February 18, 2014.
The machines measure every vital sign, every drip of fluid, every drop excreted. Each has an associated noise “informing” us that the event has occurred at the appropriate time. The never-ending chimes, bells, and buzzers echo throughout the halls of hospitals where patients are supposed to be resting and recovering. As each machine announces the patients’ progress, the cacophony increases and violates the healing environment, creating anxiety for both the patients and the nursing staff.
Anyone who has spent a night in the hospital, either as a patient or at the bedside of a loved one, knows all those sounds are disturbing. They interfere with sleep, interrupt calming positive thoughts of healing, and cause worry about what is happening to other patients or what the noise from one’s own machine means.
Years ago, there were signs in the hospital reminding us “the patient must have absolute quiet.” Even then we knew, perhaps only tacitly, that undisturbed sleep of adequate duration is required to recover from illness or surgery (patients) or maintain our performance and health (hospital staff).
More recently, research has shown that the most powerful disruptors of sleep are automatic noises designed, intentionally, to alert, even when the signaling devices are on a quiet setting.1,2 The hospital, once considered a quiet zone, is now a chaotic riot of distracting noise. Clearly, one would not describe this scenario as conducive to healing.
Alarm systems, designed to alert caregivers to potential problems with a patient, have increased over time—and with them, the noise level. There are now so many different alarms that we have become inured to them. This desensitization, known as alarm fatigue, can lead to inappropriate responses to the alarms. In some cases, this has included decreasing the alarm volume, disabling the alarm, or setting the alarm beyond safety limits.3
As a result, the problem is far more serious than the distraction or disruption the noises cause. Between 2005 and 2008, the FDA received 566 reports of patient deaths related to the alarms on monitoring devices.4 In one case highlighted by the agency, an infant died when staff overlooked the visual cues on its heart rate monitor; it turned out that the audible alarm notification had not been set up. In another, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor issuing an alert. Although the monitor had detected the problem, its dysrhythmia processing had been turned off.
The FDA and the Association for the Advancement of Medical Instrumentation jointly convened a summit to investigate this disconcerting issue in October 2011. They recognized a window of opportunity to place the hazards and frustrations of alarm fatigue on the safety agenda. The committee emphasized the need to keep the focus on patient safety first and foremost, as this will provide a sense of urgency to the issue, and outlined an ambitious goal that by 2017, “no patient will be harmed by adverse alarm events.”5
So what exactly is alarm fatigue? Continue reading to find out...
So what exactly is alarm fatigue? There is not yet a standard definition, but summit participants offered a variety of interpretations and examples. Many of them describe the consequences of alarm fatigue, such as:
• A nurse or other caregiver being overwhelmed with 350 alarm conditions per patient per day.
• Patients’ inability to rest with the multitude of alarms sounding in the room.
• A true life-threatening event lost amid the noise of multiple devices with competing signals—often leaving staff uncertain of which to address first or how to respond.
They also noted that technology is driving process, rather than the other way around.5
Recently, Wong, Mabuyi, and Gonzalez3 found that more than 95% of hospitals are concerned about alarm fatigue. That concern has now extended beyond individual hospitals and gained the attention of The Joint Commission (TJC). Following reports of 80 alarm-related deaths that occurred between January 2009 and June 2012, TJC issued a Sentinel Event Alert6 in April 2013, addressing medical device alarm safety in hospitals. The commission noted that “these devices present a multitude of challenges ... for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.”
Taking the quest for a solution a step further, in June 2013, TJC approved a new National Patient Safety Goal (NPSG) on clinical alarm safety for hospitals.7 The NPSG, which took effect in January 2014, requires that hospitals initiate improvements to ensure alarms on medical equipment are heard and responded to in a timely fashion.7
Implementation of this NPSG will occur in two phases. In Phase I (which started in January 2014), administrators will be required to “establish alarm system safety as a hospital priority” and identify the most important signals to manage based on their own internal situations (including an assessment of the risk to the patient if the alarm is ignored and whether the alarm unnecessarily contributes to the noise level). In Phase II (commencing January 2016), hospitals will be expected to develop and implement specific policies and procedures, including clinically appropriate settings for alarms and who has the authority to change the settings or set parameters to “off.” Education on alarm system management will also be required for all those in the organization who may interact with the monitoring equipment.7
We must find ways to minimize the noise and stress, for our sakes as well as our patients’—but we must do so without sacrificing safety. How do you see this playing out? Share your thoughts and ideas with me at [email protected].
Personally, I can see it now: A hospital with all the technology of the future, but without the “bells and whistles.” Finally, peace and quiet!
Continue for the references...
REFERENCES
1. Solet JM, Buxton OM, Ellenbogen JM, et al. Evidence-based Design Meets Evidence-based Medicine: the Sound Sleep Study. Concord, CA: The Center for Health Design; 2010.
2. Ellenbogen JM, Buxton OM, Wang W, et al. Sleep disruption due to hospital noises. In: Griefahn B, ed. 10th International Congress on Noise as a Public Health Problem 2011. Vol 2. London, UK: Institute of Acoustics; 2011: 618-626.
3. Wong M, Mabuyi A, Gonzalez B; Physician-Patient Alliance for Health & Safety. First National Survey of Patient-Controlled Analgesia Practices (2013). http://ppahs.files.wordpress.com/2013/10/ppahs-sasm-hand out.pdf. Accessed February 18, 2014.
4. FDA. Alarming Monitor Problems [podcast]. FDA Patient Safety News. Show #106; January 2011.
5. Association for the Advancement of Medical Instrumentation. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit (2011). www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf. Accessed February 18, 2014.
6. The Joint Commission. Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013. www.jointcommission.org/sea_issue_50. Accessed February 18, 2014.
7. The Joint Commission. National Patient Safety Goal on Alarm Management. NPSG.06.01.01. www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf. Accessed February 18, 2014.