NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Mar.
Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet].
Show detailsIntroduction
Alarm fatigue occurs when clinicians experience high exposure to medical device alarms, causing alarm desensitization and leading to missed alarms or delayed response. As the frequency of alarms used in healthcare rises, alarm fatigue has been increasingly recognized as an important patient safety issue. Although the problem of alarm fatigue has been well documented, alarm-related events are often underreported, and there is still limited research examining interventions to address the issue.1 In this chapter, we discuss two system-level patient safety practices (PSPs) that aim to address alarm fatigue: safety culture and risk assessment.
Addressing alarm fatigue through improving safety culture involves system-wide interventions, such as leadership ensuring that there are clear processes in place for safe alarm management and establishing practices to share information about alarm-related incidents and prevention strategies. The studies included in this summary provide moderate evidence for reduction in total alarms and noise level following the implementation of features of safety culture. Surveys assessing nurses’ perceptions of alarm fatigue and behavior changes regarding alarm management showed mixed results; however, two studies reported perceived reduction in alarm fatigue. More high-quality studies are needed to test the effects of safety culture elements on process and outcome measures related to alarm fatigue.
Performing baseline alarm risk assessments is an important step in order to understand current needs and conditions contributing to alarm fatigue. Conducting an alarm risk assessment can include evaluating medical devices and computer systems, analyzing data from clinical event reporting systems, and assessing patient satisfaction and the physical environment. There is currently limited research studying the impact of conducting alarm risk assessments on reducing alarm fatigue. The studies in this review examined alarm risk assessments as a component of larger quality improvement (QI) projects or system-wide initiatives; still, they provide moderately strong evidence supporting the use of multidisciplinary teams to conduct these assessments.
Background
Healthcare continues to become increasingly computerized, and clinicians use an assortment of equipment and technology to monitor patient conditions. Most healthcare devices provide auditory or visual warnings intended to alert clinicians when a patient’s condition deviates from a predetermined normal range. Many device alarms emit different sounds, tones, and/or pitches depending on the level of severity (i.e., advisory vs. warning vs. crisis alarms) to help clinicians determine how to respond. System status or non-clinical alarms can also occur and are caused by mechanical or electrical problems, such as a device needing new batteries.2 Device alarms can be an important tool to assist in clinical decision making; however, alarms can become hazardous to patient safety if excessive alarm frequency coupled with high prevalence of false alarms leads to alarm fatigue.
Alarm fatigue occurs when clinicians, especially nurses, become desensitized to safety alarms due to the sheer number of alarm signals,3 which in turn can lead to missed alarms or delayed response.1 Alarm desensitization is compounded by the fact that false or nonactionable alarms occur frequently. False alarms are those that occur in the absence of an intended valid event,4 and nonactionable alarms occur when an alarm system works as designed but signifies an event that is not clinically significant and/or requires no additional intervention.5 The high volume of these nuisance alarms is not only disruptive, but also creates a situation where staff doubt the reliability of alarms and as a result turn down the volume, ignore, or deactivate the alarms.5 This adversely affects patient safety because clinicians are not only ignoring the nuisance alarms, but also ignoring or missing many clinically significant and actionable alarms.3
Importance of Harm Area
Alarm fatigue is increasingly recognized as a critical safety issue, and alarm management has become a priority for improvement in hospitals. From 2005 to 2008, the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) reporting system received 566 reports of patient deaths related to monitoring device alarms.6 Alarm fatigue was a major contributor to these events due to the excessive number of alarms and high percentage of false alarms.6 A study at a major academic medical center found a total of more than 59,000 alarms over a 12-day period,1 while another study found 16,953 total alarms over an 18-day period on a single medical unit.7 Studies have shown that the percentage of false alarms can range from 72 percent to 99 percent.1
In growing awareness of this issue, a number of national organizations have established alarm management guidelines and prioritize addressing alarm fatigue. Since initiating its annual list of top 10 health technology hazards in 2011, the ECRI Institute has consistently identified alarm hazards as a top issue.8 In 2011, the Association for the Advancement of Medical Instrumentation (AAMI) convened a summit with FDA, the Joint Commission, the American College of Clinical Engineers, and the ECRI Institute to address the issue of alarm safety, and published a report outlining recommendations, challenges, and priority actions.9 In 2013, the Joint Commission published a Sentinel Event Alert on medical device alarm safety, which identified alarm fatigue as a main contributing factor to patient deaths.1 Later that year, the Joint Commission released its 2014 National Patient Safety Goal on Alarm Management in two phases of implementation. Beginning in 2014, hospitals were required to establish alarms as an organization-wide priority and identify the most important alarms to manage based on their own internal situations. Beginning in 2016, hospitals were expected to establish policies for managing alarms and educate staff about alarm management.10
Methods for Selecting PSPs
Initial literature searches for PSPs in the alarm fatigue harm area were conducted, focusing on systematic reviews and guidelines. Results of these searches were reviewed by harm-area task leads to identify PSPs, iterate on searches as needed, and refine lists of potential alarm fatigue PSPs on which to focus for the report. Then the project Technical Expert Panel and Advisory Group were engaged via a survey to prioritize PSPs for inclusion in the report. These survey results, along with refined recommendations for PSP inclusion, were submitted to the Agency for Healthcare Research and Quality (AHRQ) for review. After several rounds of review with AHRQ, two alarm fatigue PSPs were selected.
What’s New/Different Since the Last Report?
The potential for harm due to alarms’ high frequency and low specificity was briefly discussed in the report Making Health Care Safer I, and alarm fatigue was mentioned in Making Health Care Safer II in respect to computerized provider order entry with clinical decision support systems. This is the first Making Health Care Safer report to include an evidence review of alarm fatigue as a harm area and look at interventions specifically related to addressing alarm fatigue.
References for Introduction
- 1.
- Sendelbach S, Funk M. Alarm fatigue: A patient safety concern. AACN Adv Crit Care. 2013;24(4):378–86; quiz 87-8. doi: 10.1097/NCI.0b013e3182a903f9. [PubMed: 24153215] [CrossRef]
- 2.
- Healthcare Technology Foundation. A Guide to Understanding Clinical Alarms. 2016. http://thehtf
.org/documents /A%20Guide%20to %20Understanding%20Clinical%20Alarms .pdf. - 3.
- Agency for Healthcare Research and Quality. Patient Safety Primer: Alarm Fatigue. https://psnet
.ahrq.gov/primers/primer/28. Accessed December 17, 2019. - 4.
- ACCE Healthcare Technology Foundation. Impact of Clinical Alarms on Patient Safety 2006.
- 5.
- Welch J. Alarm fatigue hazards: The sirens are calling. https://www
.psqh.com /analysis/alarm-fatigue-hazards-the-sirens-are-calling/. Accessed December 17, 2019. - 6.
- Bach T, Berglund L, Turk E. Managing alarm systems for quality and safety in the hospital setting. BMJ Open Qual. 2018;7(3):e000202. doi: 10.1136/bmjoq-2017-000202. [PMC free article: PMC6069923] [PubMed: 30094341] [CrossRef]
- 7.
- Graham K, Cvach M. Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19(1):28–34; quiz 5. doi: 10.4037/ajcc2010651. [PubMed: 20045845] [CrossRef]
- 8.
- Joint Comission on Accreditation of Healthcare Organizations. Sound the Alarm: Managing Physiologic Monitoring Systems. The Joint Commission on Patient Safety; 2011. https://www
.jointcommission .org/assets/1 /6/Perspectives_Alarm.pdf. - 9.
- Association for the Advancement of Medical Instrumentation. A Siren Call for Action – Priority Issues From the Medical Device Alarms Summit. 2011. http://kami
.camp9.org /Resources/Pictures /2011%20Alarms%20Summit%20Report.pdf. - 10.
- The Joint Comission. The joint commission announces 2014 national patient safety goal. 2013. https://www
.beckershospitalreview .com/quality /joint-commission-releases-2014-national-patient-safety-goals.html. [PubMed: 24137865]
13.1. Patient Safety Practice 1: Safety Culture
13.1.1. Practice Description
Establishing a culture of safety is essential to improving overall healthcare quality. Broadly, key features of safety culture include: acknowledgment of the high-risk nature of an organization’s activities; a blame-free environment where individuals are able to report errors without fear of punishment; encouragement of collaboration across staff levels and disciplines to seek solutions to patient safety problems; and an organizational commitment of resources to address safety concerns.1 Addressing alarm fatigue through improving safety culture can involve a variety of interventions that are often implemented as a system-wide or unit-wide initiative. Examples of these elements include the following: leadership ensures there are clear processes in place for safe alarm management and response; leadership establishes priorities for the adoption of alarm technology; and at all staffing levels, practices are established to share information about alarm-related incidents, prevention strategies, and lessons learned. This section reviews efforts to address alarm fatigue through improving safety culture; clinical outcome measures and provider perceptions, as well as barriers and facilitators to implementation, are examined.
13.1.2. Methods
Two databases (CINAHL® and MEDLINE®) were searched for articles published from 2008 to 2019 using the terms “alarm fatigue,” “alarm management,” and related synonyms, as well as “safety culture,” “protocol,” “leadership,” and other similar terms. The initial database search yielded 117 results. Once duplicates were removed and 8 additional relevant articles from selected other sources were added, a total of 114 articles were screened for inclusion. Five of the eight additional articles from other sources were identified through a manual search of the Joint Commission, ECRI Institute, and AAMI websites for relevant case studies. Due to the overlap between Safety Culture and Risk Assessment for this topic, three additional articles from other sources were identified from the Risk Assessment literature search that were also relevant for this patient safety practice (PSP), and they were reviewed. After screening the 114 articles, 63 full-text articles were retrieved, of which 17 in total were selected for inclusion in this review. Articles were excluded if the outcomes were not relevant to this review, the article was out of scope, or the article did not describe an intervention.
Finally, after reviewing the initial set of full-text articles retrieved, we ran one additional search with the term “alarm desensitization” and related synonyms, which did not yield any relevant results.
General methods for this report are described in the Methods section of the full report.
For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report A through C appendixes.
13.1.3. Review of Evidence
A summary of key findings related to alarm management safety culture is located in the Key Findings box. The following section reviews the applicable studies in more depth by measure type. Of the 17 studies included in this review, 10 were QI initiatives, 5 were case studies, 1 was a quasi-experimental study, and 1 was an observational study. All took place in the hospital setting, with 4 of the 17 studies examining the establishment of safety culture to address alarm fatigue hospital-wide. The remaining 13 studies examined the implementation of this PSP in a specific unit, including the intensive care unit (ICU), progressive care unit (PCU), neonatal intensive care unit (NICU), and telemetry, step-down, transplant, cardiology, surgical, and surgical orthopedic units.
Key Findings
Clinical Outcomes
- Eight studies found a decrease in the total number of alarms, including three studies that reported a decrease in the number of false alarms.
- Two studies found an overall reduction in noise level post-intervention in the study units.
Facilitators
- Securing buy-in from staff at all levels is key to achieving culture change.
- Cultural change was necessary throughout the unit to transition from alarm management being considered a nursing concern to everyone taking responsibility for alarm management.
- Changing the culture to recognize that patient safety is everyone’s responsibility and each staff member has the duty to address alarms was an important step in improving care.
To evaluate the impact of implementing safety culture elements on alarm fatigue, the studies included in this review measured both clinical outcomes that are indicators of alarm fatigue as well as behavioral outcomes related to providers’ perceptions of culture change.
13.1.3.1. Clinical Outcomes
Clinical outcome measures for alarm fatigue were reported in eight studies. Outcomes in these studies included total number of alarms, alarm rate, number of false alarms, and noise level. Clinical alarms are intended to provide a quick patient assessment; however, a high abundance of alarms, the majority of which are often false alarms, diminishes their efficacy. To address this abundance, the studies included in this review primarily sought to decrease overall alarm burden. The authors of the included studies note that they first identified which types of alarms were the greatest contributors to alarm fatigue and targeted those, so a decrease in overall number of alarms is consider a positive outcome.
De Vaux et al. observed 23–26 patients in a step-down unit over a 2-week period pre-implementation of the American Association of Critical-Care Nurses’ (AACN) clinical toolkit to improve safety of alarm management and at three points post-intervention. The authors found that the total number of alarms decreased from 251 pre-intervention to 12 at 6 months post-intervention. They also found a decrease in the number of false alarms from 201 to 12 and a decrease in nonactionable alarms from 122 to 6 over the same time period.2 Dandoy et al. reported that during implementation of a standardized cardiac monitor care process, which included daily electrode changes, daily evaluation of monitor parameters, and timely discontinuation of monitor use, the median number of cardiac alarms per monitored patient day decreased from 180 to 40 over 11 months, and the median number of false alarms decreased from 95 percent to 50 percent.3 Rayo et al. found that after implementing a new continuous cardiac monitoring policy, the percentage of false alarms decreased from 18.8 percent to 9.6 percent, but the percentage of unnecessary alarms remained consistent.4
Five additional studies examined the change in total number of alarms, but did not measure the number of false or nonactionable alarms. A study by Epstein et al. showed that over 4 months the pilot telemetry unit successfully lowered its total number of alarm signals by 69 percent.5 In addition, Graham and Cvach found a 43-percent reduction in physiological monitor alarms,6 Vockley found a 30-percent decrease in alarm signals,7 and Whalen et al. found an 89-percent reduction in total number of audible alarms per week.8 Finally, Srinivasa et al. reported a 54-percent reduction in the total alarm rate (alarms per bed per day).9 Many of the interventions included in these studies were multifaceted so it is difficult to conclude which elements contributed to the changes in alarm frequency. Some of the facilitators, however, included small tests of change, educating staff on better alarm management, and empowering nursing staff to change default alarm settings. Additional facilitators are summarized below.9
In addition to number of alarms, alarm volume was used as a clinical outcome measure of alarm fatigue. Excessive alarm noise creates an unpleasant work environment and contributes to alarm fatigue as staff become desensitized to the white noise. Two studies measured noise level before and after an alarm-reduction patient safety intervention, and both found overall reductions in noise level in the study units. Srinivasa et al. reported that average noise in decibels (dB) for the left wing and main hallway of a surgical telemetry unit dropped from 58.94dB to 57.84dB and from 58.04dB to 54.43dB, respectively, pre- to post-intervention.9 Whalen et al. found that the decibel level narrowed from a range of 54–90dB to 60–72dB after implementing a pilot QI project in a medical cardiology unit.8
13.1.3.2. Behavioral Outcomes
Safety culture is typically measured by surveying clinicians.1 In this review, eight studies included surveys measuring physician and clinical staff perceptions, satisfaction, and understanding of procedures and factors related to implementation of the PSP.
Two studies included surveys exploring alarm fatigue. Results of a survey by Alsaad et al., before and after implementing guidelines and protocols for reducing alarms in cardiac telemetry, found a 27-percent reduction in a score of perceived alarm fatigue.10 In a survey by Ketko et al., most respondents reported they felt that alarm fatigue was being addressed and alarm frequency decreased as a result of the implementation of processes for safe alarm management and response.11
Two studies asked nurses about their perception of alarm noise. Graham and Cvach found that nurses perceived the unit’s overall noise level as lower after implementing changes to reduce alarms.6 Whalen et al. found that the percentage of nurses who assessed the noise level on the unit as acceptable increased from 0 percent to 64 percent post-intervention.8
Three studies included surveys that asked clinicians about their perceptions and behaviors related to alarm management processes. The results from these surveys were mixed. For example, in a survey by Cameron and Little, 66 percent of nurses agreed or strongly agreed that they had improved their alarm management practices as a result of the new alarm policy, and there was a significant improvement in nurses selecting the appropriate intervention to manage an alarm. The same study, however, also reported that nurses’ perceptions about alarms were more negative after the initiative in terms of reducing attention to patients, feeling overwhelmed by alarms, alarms contributing to stress levels, and situations requiring alarm disabling.12
Petersen and Costanzo, surveyed nurses about their knowledge of their hospital’s initiatives to reduce alarm fatigue, and found that 58 percent of responding nurses felt that clinical policies and procedures were effectively used to manage alarms. However, only 15 percent of responding nurses recognized that a new alarm management team had been implemented to assess current needs, edit policies, decrease alarm numbers, and change the culture of alarm management. In addition, only 19 percent of responding nurses recognized that new technology had been implemented to improve clinical alarm safety. Overall, the authors concluded that these survey results showed a lack of education in alarm management and therefore incorporated training into future hospital improvement intiatives13
Clinicians’ confidence in addressing alarms may improve after implementation of an alarm management PSP. For example, after hospital-wide alarm management competency training, Allen et al. surveyed nurses and found a 13-percent decrease in the number of nurses who rated themselves as not confident in one or more aspects of monitor functionality, such as customizing patient alarms or reviewing alarm settings.14
13.1.3.3. Economic Outcomes
Only one included study measured outcomes of safety culture alarm management initiatives related to cost. Alsaad et al. calculated changes in cost (measured in dollars) for patients who were originally monitored by cardiac telemetry but were downgraded to being non-monitored after implementing new protocols. In accordance with the protocols, patients who were monitored with no clinical indications for cardiac telemetry were discontinued from monitoring and downgraded to a different inpatient status, resulting in a 42-percent cost reduction.10
13.1.3.4. Unintended Consequences
13.1.3.4.1. Negative
Authors of the studies we reviewed did not indicate many unintended negative consequences of implementing elements of safety culture to address alarm fatigue. McGrath et al. hypothesized that implementing wireless sensors would decrease the alarms caused by staff removing sensors to allow patients to move around; however, results showed a greater than expected increase in non-clinical alarms, which are associated with system status and device operation. Despite this increase, there was not a significant increase in clinical alarm rates per hour monitored, and overall alarm rates were still below a level where the authors judged that alarm fatigue would be a concern. In addition, the authors note that an increase in total number of alarms was expected in their study, because patients were monitored for a more continuous period as a result of the intervention.15
13.1.3.4.2. Positive
Positive unintended consequences were mentioned by a few authors. De Vaux et al. reported an incidental finding that default-setting parameters were more often customized to match a patient’s clinical condition after the intervention. Pre-intervention, 39.0 percent of alarms were customized to diverge from the preset default settings (e.g., using a higher threshold to trigger the alarm), and after implementing guidelines for alarm management, 87.5 percent of alarms were customized.2
Vockley and Kloewer noted that introducing a new technology into a healthcare setting typically increases alarm burden, but the researchers observed that after introducing a continuous surveillance monitoring system, there were fewer and more meaningful alarms, and staff expressed higher trust that the system would relay clinically significant alarm signals, therefore easing the burden.16
13.1.4. Implementation
13.1.4.1. Summary of Evidence on Implementation
Improving the culture of safety in a unit or hospital can be difficult, and this PSP includes a variety of interventions involving commitment to a culture of safety by all staff at all levels, as well as changes to processes, workflows, and policies that embody this commitment. The studies we reviewed implemented a variety of changes that were specific to the unique needs of the hospital, unit, or type of monitor/alarm. Across these varied initiatives, some common themes of facilitators and barriers emerged.
13.1.4.2. Facilitators and Barriers
13.1.4.2.1. Facilitators
Buy-in, especially from leadership, can greatly facilitate an effective change in safety culture. Eight of the 17 studies directly mentioned that leadership was involved in developing and implementing the safety culture alarm fatigue PSP. For example, Jahrsdoerfer noted that hospital leaders decided to update existing alarm management processes to maximize use of modern technology.17 Cameron et al., Rayo et al., and Whalen et al. also highlighted that strong leadership support was a key factor in successful implementation.4,8,12 In addition to leadership commitment, securing buy-in from staff at all levels facilitates culture change. Whalen et al. noted that nurses became strong advocates of the project, which resulted in sustained change,8 and Graham and Cvach attributed achieving true culture change in alarm management to having complete buy-in from staff.6 AAMI also noted that a key to success was that technology matched the culture of change, and there was strong support from all stakeholders involved.18 A survey respondent in a study by Petersen and Costanzo stated that an important step in improving care is changing the culture to recognize that patient safety is everyone’s responsibility and each staff member has the duty to address alarms.13 Echoing this, Ketko et al. noted that cultural change was necessary throughout the unit to transition from alarm management being considered a nursing concern, to everyone taking responsibility for alarm management.11
Another common theme identified as an implementation facilitator was the effort to standardize procedures. For example, Allen et al. stated that the health system’s leaders, after recognizing a lack of standardized protocols, established a new protocol and adopted an evaluation tool across all departments in the system.14 In addition, Graham and Cvach noted that the hospital did not have standards for alarm response before the QI project began, but as a result of the initiative, standardized education and a hospital-wide monitor protocol were implemented to improve alarm management.6 Finally, Dandoy et al. noted that the aim of their project was to implement a standardized, team-centered process for cardiac monitoring to decrease nuisance alarms.3
13.1.4.4.2. Barriers
If a newly implemented alarm management process is not clearly defined or training is incomplete, adherence by clinical staff can be suboptimal. For example, Dandoy et al. found that when the cardiac monitor care process was first implemented, compliance was 33–43 percent. After roles and responsibilities were clearly defined, however, compliance increased to 73–98 percent.3 In addition, Cameron and Little, Epstein et al., and Vockley and Kloewer noted the importance of ongoing training to educate providers about alarm management.5,7,12
13.1.4.3. Resources To Assist With Implementation
The AAMI Foundation National Coalition for Alarm Management Safety brings together stakeholders to discuss strategies to improve alarm management, and provides resources and toolkits for healthcare organizations to begin work in this area. The ECRI Institute developed The Alarm Safety Handbook and Workbook, which outline the measures healthcare facilities should take to effectively manage alarms. The National Association of Clinical Nurse Specialists Alarm Fatigue Toolkit provides recommendations and resources to help clinical nurse specialists effectively manage alarms and combat alarm fatigue.
13.1.5. Gaps and Future Directions
The current literature on this PSP primarily concerns QI initiatives and case studies; higher quality studies could help to better understand the impact of implementing elements of safety culture to address alarm fatigue. In addition, because efforts to improve safety culture typically involve multiple elements and are often part of a larger hospital-wide initiative, it is difficult to know which intervention(s) are most responsible for reducing alarm fatigue. The studies we reviewed had small sample sizes and focused on one hospital or specific unit, and often one type of monitor/alarm, and may have limited generalizability.
References for Section 13.1
- 1.
- Agency for Healthcare Research and Quality. Patient Safety Primer: Culture of Safety https://psnet
.ahrq.gov /primers/primer/5/Culture-of-Safety. Accessed December 17, 2019. - 2.
- De Vaux L, Cooper D, Knudson K, et al. Reduction of nonactionable alarms in medical intensive care. Biomed Instrum Technol. 2017;51(s2):58–61. doi: 10.2345/0899-8205-51.s2.58. [PubMed: 28296452] [CrossRef]
- 3.
- Dandoy C, Davies S, Flesch L, et al. A team-based approach to reducing cardiac monitor alarms. Pediatrics. 2014;134(6):e1686–e94. doi: 10.1542/peds.2014-1162. [PubMed: 25384493] [CrossRef]
- 4.
- Rayo M, Mansfield J, Eiferman D, et al. Implementing an institution-wide quality improvement policy to ensure appropriate use of continuous cardiac monitoring: A mixed-methods retrospective data analysis and direct observation study. BMJ Qual Saf. 2016;25(10):796–802. doi: 10.1136/bmjqs-2015-004137. [PubMed: 26566801] [CrossRef]
- 5.
- Epstein M, Smith K, Snavely V. Fighting Alarm Fatigue With Data-Driven Interventions. AAMI Foundation; 2016. https://www
.aamifoundation .org/wp-content /uploads/2018/11/2016 _SI_NCH_Fighting_Alarm_Fatigue.pdf. - 6.
- Graham K, Cvach M. Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19(1):28–34; quiz 5. doi: 10.4037/ajcc2010651. [PubMed: 20045845] [CrossRef]
- 7.
- Vockley M. Plan, Do, Check, Act: Using Action Research to Manage Alarm Systems, Signals, and Responses. AAMI Foundation Healthcare Technology Institute 2012. http://s3
.amazonaws.com /rdcms-aami/files /production/public/FileDownloads /Foundation /SafetyInnovation /2012_SI_Plan_Do_Check_BethIsrael.pdf. - 8.
- Whalen D, Covelle P, Piepenbrink J, et al. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2014;29(5):E13–E22. doi: 10.1097/JCN.0000000000000114. [PubMed: 24365870] [CrossRef]
- 9.
- Srinivasa E, Mankoo J, Kerr C. An eevidence-based approach to reducing cardiac telemetry alarm fatigue. Worldviews Evid Based Nurs. 2017;14(4):265–73. doi: 10.1111/wvn.12200. [PubMed: 28432853] [CrossRef]
- 10.
- Alsaad A, Alman C, Thompson K, et al. A multidisciplinary approach to reducing alarm fatigue and cost through appropriate use of cardiac telemetry. Postgrad Med J. 2017;93(1101):430–5. doi: 10.1136/postgradmedj-2016-134764. [PubMed: 28455284] [CrossRef]
- 11.
- Ketko A, Martin C, Nemshak M, et al. Balancing the tension between hyperoxia prevention and alarm fatigue in the nicu. Pediatrics. 2015;136(2):e496–e504. doi: 10.1542/peds.2014-1550. [PubMed: 26148949] [CrossRef]
- 12.
- Cameron H, Little B. Nurses’ perceptions and practices related to alarm management: A quality improvement initiative. J Contin Educ Nurs. 2018;49(5):207–15. doi: 10.3928/00220124-20180417-05. [PubMed: 29701862] [CrossRef]
- 13.
- Petersen E, Costanzo C. Assessment of clinical alarms influencing nurses’ perceptions of alarm fatigue. Dimensions Of Critical Care Nursing: DCCN. 2017;36(1):36–44. [PubMed: 27902661]
- 14.
- Allen J, Hileman K, Ward A. Simple Solutions for Improving Patient Safety in Cardiac Monitoring—Eight Critical Elements To Monitor Alarm Competency. AAMI Foundation Healthcare Safety Instiute; 2013.
- 15.
- McGrath S, Perreard I, Garland M, et al. Improving patient safety and clinician workflow in the general care setting with enhanced surveillance monitoring. IEEE J Biomed Health. 2019;23(2):857–66. doi: 10.1109/JBHI.2018.2834863. [PubMed: 29993903] [CrossRef]
- 16.
- Vockley M, Kloewer T. Safety innovations: Vital signs monitoring leads to increased patient safety and workflow efficiency. Biomed Instrum Technol. 2017;51(6):484–92. doi: 10.2345/0899-8205-51.6.484. [PubMed: 29161117] [CrossRef]
- 17.
- Jahrsdoerfer M. Case study: Reducing interruption fatigue through improved alarm support. Biomed Instrum Technol. 2016;50(2):109–13. doi: 10.2345/0899-8205-50.2.109. [PubMed: 27046685] [CrossRef]
- 18.
- AAMI. Safeguarding Patients With Surveillance Monitoring. AAMI Foundation Healthcare Technology Safety Institute; 2013. http://s3
.amazonaws.com /rdcms-aami/files /production/public/FileDownloads /Foundation /SafetyInnovation /2013_SI_Surveillance _Dartmouth_Hitchcock.pdf.
13.2. Patient Safety Practice 2: Risk Assessment
13.2.1. Practice Description
Risk management is crucial to promoting safer healthcare and proactively identifying, prioritizing, and mitigating patient safety risk. Many national organizations recognize that conducting a baseline alarm assessment to understand current needs and conditions contributing to alarm fatigue is an important step in alarm management. For example, the AAMI Foundation recommends, as one of its Ten Ideas for Safe Alarm Management, engaging a multidisciplinary team to prepare an alarm inventory risk analysis and gap analysis that identifies patient safety vulnerabilities that could be amenable to change.1 In addition, an element of performance for the Joint Commission’s National Patient Safety Goal on Alarm Management is to “identify the most important alarm signals to manage based on: input from the medical staff and clinical departments; risk to patients if the alarm signal is not attended to or if it malfunctions; whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue; potential for patient harm based on internal incident history; and published best practices and guidelines.”2 Conducting an alarm risk assessment can include evaluating medical devices and computer systems, including the default alarm settings; assessing patient satisfaction (e.g., sleep interruption from nuisance alarms); and assessing the physical environment to determine whether clinically significant alarm signals are audible to staff. In addition, healthcare settings may use data from event reporting systems to identify actual or near-miss harm reported by staff as a method of risk assessment. This section briefly reviews studies in healthcare facilities that engaged multidisciplinary alarm management teams to conduct alarm risk assessments.
13.2.2. Methods
Two databases (CINAHL® and MEDLINE®) were searched for articles published from 2008 to 2019 using the terms “alarm fatigue,” “alarm management,” and related synonyms, as well as “management,” “risk assessment,” “interdisciplinary,” “committee,” and other similar terms. The initial database search yielded 186 results. Once duplicates were removed and seven additional relevant articles from selected other sources were added, a total of 167 articles were screened for inclusion and 47 full-text articles were retrieved. Of those, 13 were selected for inclusion in this review. Articles were excluded if the outcomes were not relevant to this review, the article was out of scope, or the article did not describe an intervention.
To identify additional articles from other sources, we conducted a manual search of the Joint Commission, ECRI Institute, and AAMI websites for relevant case studies. This yielded three articles that we included. In addition, due to the overlap between Safety Culture and Risk Assessment for this topic, we identified three articles from the Safety Culture literature search that are also relevant for this PSP and were reviewed. Finally, we scanned the reference sections of all full-text articles retrieved and, as a result, identified one additional article for inclusion. These seven articles brought the total number of articles included in this review to 13.
Finally, after reviewing the initial set of full-text articles retrieved, we ran one additional search with the term “alarm desensitization” and related synonyms, which did not yield any relevant results.
General methods for this report are described in the Methods section of the full report.
For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report A through C appendixes.
13.2.3. Review of Evidence
Of the 13 studies included in this review, 10 were QI initiatives and 3 were case studies. All took place in the hospital setting, with 3 of the 13 studies examining the implementation of this PSP hospital-wide. The remaining 10 studies examined establishing a multidisciplinary alarm management committee to conduct ongoing alarm risk assessment in a specific unit, such as the ICU, PCU, NICU, or step-down, transplant, cardiology, surgical, or surgical orthopedic units.
All the articles included in the review of this PSP are also included in Chapter 17, Section 17.2, Safety Culture. After reviewing the literature, we found that in all the relevant studies, hospitals engaged teams to conduct an alarm fatigue risk assessment as a component of a larger QI project or system-wide initiative. In fact, for many of the studies, the team’s assessment informed the creation and implementation of the safety culture initiative. Due to this overlap, many of the clinical and behavioral outcome measures for alarm fatigue detailed in the previous section are the same for this review. Highlights from these findings are briefly summarized in the Key Findings box. In addition to the outcomes measuring indicators of alarm fatigue, these studies also included outcomes from the alarm risk assessments. They are briefly described below.
13.2.3.1. Multidisciplinary Risk Assessment
The multidisciplinary teams assembled for these initiatives conducted risk assessments to understand the current state of alarm management and identify which alarms contributed most to alarm fatigue. Three studies mentioned specific methods used to conduct the analysis. In a study by Vockley, a multidisciplinary team evaluated the use of cardiac alarm technology using Failure Mode and Effects Analysis, which is a step-by-step approach for identifying errors and studying their potential consequences.3 Similarly, a team in a study by AAMI conducted a Failure Mode and Effects Analysis, and Cameron and Little studied a team using Failure Mode Effects and Critical Analysis to assess alarm risk.4,5 In a study by De Vaux et al., an alarm management team used a gap analysis assessment tool from the American Association of Critical-Care Nurses to assess alarm safety.6
Key Findings
Clinical Outcomes
- Five studies found a decrease in the total number of alarms.
- Three studies reported a decrease in the number of false alarms.
- Two studies found an overall reduction in noise level post-intervention in the study units.
The results from these multidisciplinary assessments varied due to the diverse range of hospital units and monitors that were studied. For example, a QI team, in a study by Cameron and Little, conducted a hospital-wide analysis and found that telemetry, pulse oximetry, intravenous pumps, and the fire alarm system were the most troublesome for nursing staff.5 In a study by Whalen et al., a telemetry task force learned from clinicians that two types of arrhythmia alarms often created unnecessary noise because they occurred frequently but were rarely clinically significant.7 De Vaux et al. reported that as a result of an alarm management team’s assessment, audible alarms from bedside physiologic monitors were identified as the largest contributor to noise level in the medical ICUs.6
In addition to assessing the types of monitor that contribute to alarm fatigue, some studies focused on a specific type of alarm, and multidisciplinary teams assessed the current practices for managing those alarms. For example, Dandoy et al. noted that a team reviewed the cardiac monitor care process to identify gaps in practice and areas for improvement.8 Vockley reported that a team found that 40 percent to 50 percent of patients in the general medical and surgical units were monitored on cardiac telemetry, but there were no consistent criteria about which patients should be placed on cardiac telemetry monitoring.3
13.2.4. Implementation
13.2.4.1. Summary of Evidence on Implementation
Many of the barriers and facilitators to engaging a multidisciplinary team to conduct an alarm risk assessment are similar to those for implementing elements of safety culture to address alarm fatigue—most importantly, support from leadership and staff. This section reviews additional implementation facilitators that are specific to alarm risk assessment.
13.2.4.2. Facilitators
Engaging a team that includes stakeholders from different disciplines is an important facilitator of effectively assessing alarm fatigue risk. All the studies included in this review specifically mentioned that the multidisciplinary assessment team included representatives beyond just clinical staff, and several noted the important contributions of these additional stakeholders. For example, AAMI noted the importance of including biomedical, human factors, and cognitive systems engineers on the team to ensure that changes in a surveillance system caused no undue burden for patients and clinicians.4 Epstein et al. found that a vendor representative on the alarm management committee helped ensure that the hospital was compliant with the alarm management goal, provided current best practice recommendations, and assisted with analysis of device integration.9 Rayo et al. found that human factors engineers, clinicians, and IT professionals working together led to solutions that optimized usability and mitigated risks. In addition, guidance from human factors engineers led the team to measure true, false, and unnecessary alarms, which are reliable predictors of alarm response.10 In addition, Ketko et al. noted that acknowledging alarm management as a collaborative effort was an important first step in the initiative.11
The decision to engage a team and conduct a risk assessment was often in response to a specific adverse patient event or external influence. For example, Vockley notes that after two sentinel events involving alarm signals at the studied hospital, a team was formed to investigate the incidents and conduct a larger assessment of the current alarm use practices.3 Whalen et al. stated that leadership convened a telemetry task force to explore the issue of alarm fatigue after reports of sentinel events at other institutions.7 Four studies (Cameron and Little, De Vaux et al., Epstein et al., and Rayo et al.) noted that alarm management teams were formed in response to and with the goal of meeting the Joint Commission’s National Patient Safety Goal on Alarm Management.5,6,9,10
13.2.5. Gaps and Future Directions
As with safety culture, the studies we reviewed focused on one hospital or specific unit, so may have limited generalizability. Despite this, the research presents moderately strong evidence demonstrating the value of conducting a multidisciplinary risk assessment to address alarm fatigue.
References for Section 13.2
- 1.
- AAMI. Clinical Alarm Management Compendium. AAMI Foundation; 2015. http://s3
.amazonaws.com /rdcms-aami/files /production/public/FileDownloads /Foundation /Reports/Alarm_Compendium_2015.pdf. - 2.
- The Joint Comission. The Joint Commission Announces 2014 National Patient Safety Goals. 2013. https://www
.beckershospitalreview .com/quality /joint-commission-releases-2014-national-patient-safety-goals.html. [PubMed: 24137865] - 3.
- Vockley M. Plan, Do, Check, Act: Using Action Research To Manage Alarm Systems, Signals, and Responses. AAMI Foundation Healthcare Technology Institute; 2012. http://s3
.amazonaws.com /rdcms-aami/files /production/public/FileDownloads /Foundation /SafetyInnovation /2012_SI_Plan_Do_Check_BethIsrael.pdf. - 4.
- AAMI. Safeguarding Patients With Surveillance Monitoring. AAMI Foundation Healthcare Technology Safety Institute; 2013. http://s3
.amazonaws.com /rdcms-aami/files /production/public/FileDownloads /Foundation /SafetyInnovation /2013_SI_Surveillance _Dartmouth_Hitchcock.pdf. - 5.
- Cameron H, Little B. Nurses’ perceptions and practices related to alarm management: A quality improvement initiative. J Contin Educ Nurs. 2018;49(5):207–15. doi: 10.3928/00220124-20180417-05. [PubMed: 29701862] [CrossRef]
- 6.
- De Vaux L, Cooper D, Knudson K, et al. Reduction of nonactionable alarms in medical intensive care. Biomed Instrum Technol. 2017;51(s2):58–61. doi: 10.2345/0899-8205-51.s2.58. [PubMed: 28296452] [CrossRef]
- 7.
- Whalen D, Covelle P, Piepenbrink J, et al. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2014;29(5):E13–E22. doi: 10.1097/JCN.0000000000000114. [PubMed: 24365870] [CrossRef]
- 8.
- Dandoy C, Davies S, Flesch L, et al. A team-based approach to reducing cardiac monitor alarms. Pediatrics. 2014;134(6):e1686–e94. doi: 10.1542/peds.2014-1162. [PubMed: 25384493] [CrossRef]
- 9.
- Epstein M, Smith K, Snavely V. Fighting Alarm Fatigue With Data-Driven Interventions. AAMI Foundation; 2016. https://www
.aamifoundation .org/wp-content /uploads/2018/11/2016 _SI_NCH_Fighting_Alarm_Fatigue.pdf. - 10.
- Rayo M, Mansfield J, Eiferman D, et al. Implementing an institution-wide quality improvement policy to ensure appropriate use of continuous cardiac monitoring: A mixed-methods retrospective data analysis and direct observation study. BMJ Qual Saf. 2016;25(10):796–802. doi: 10.1136/bmjqs-2015-004137. [PubMed: 26566801] [CrossRef]
- 11.
- Ketko A, Martin C, Nemshak M, et al. Balancing the tension between hyperoxia prevention and alarm fatigue in the NICU. Pediatrics. 2015;136(2):e496–e504. doi: 10.1542/peds.2014-1550. [PubMed: 26148949] [CrossRef]
- 12.
- Alsaad A, Alman C, Thompson K, et al. A multidisciplinary approach to reducing alarm fatigue and cost through appropriate use of cardiac telemetry. Postgrad Med J. 2017;93(1101):430–5. doi: 10.1136/postgradmedj-2016-134764. [PubMed: 28455284] [CrossRef]
- 13.
- Graham K, Cvach M. Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19(1):28–34; quiz 5. doi: 10.4037/ajcc2010651. [PubMed: 20045845] [CrossRef]
- 14.
- Petersen E, Costanzo C. Assessment of clinical alarms influencing nurses’ perceptions of alarm fatigue. Dimensions Of Critical Care Nursing: DCCN. 2017;36(1):36–44. [PubMed: 27902661]
- 15.
- Srinivasa E, Mankoo J, Kerr C. An eevidence-based approach to reducing cardiac telemetry alarm fatigue. Worldviews Evid Based Nurs. 2017;14(4):265–73. doi: 10.1111/wvn.12200. [PubMed: 28432853] [CrossRef]
Conclusion and Comment
The two PSPs reviewed in this chapter aim to address alarm fatigue by implementing hospital- or unit-wide initiatives to target nonactionable, nuisance alarms and decrease overall alarm burden. The review of evidence shows that implementing elements of safety culture can lead to a decrease in the total number of alarms, number of false alarms, and overall alarm noise level; however, since these initiatives often involve multiple components, it is difficult to know which intervention(s) have the greatest impact. The evidence also shows moderately strong support for conducting risk assessments to understand the current state of alarm management and identify which alarms are the greatest contributors to alarm fatigue. The results of these risk assessments should be used to inform the implementation of processes for safe alarm management and priorities for adoption of alarm technology. Investing in training and education for care providers on new technology as well as ensuring buy-in at all levels and engaging multidisciplinary teams are key to effectively implementing these strategies to reduce alarm fatigue.
Reviewer: Ann Gaffey, R.N., M.S.N., CPHRM, DFASHRM
- Alarm Fatigue - Making Healthcare Safer III: A Critical Analysis of Existing and...Alarm Fatigue - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices
Your browsing activity is empty.
Activity recording is turned off.
See more...