Feb 23, 2024 Assignment: Distractors in our Environment
Give an example of an ethical or legal issue that may arise if a patient has a poor outcome or sentinel event because of a distraction such as alarm fatigue. What does evidence reveal about alarm fatigue and distractions in healthcare when it comes to patient safety?
Alarm fatigue is a prevalent issue in nursing. I have floated to the telemetry unit at my hospital and witnessed it first-hand, and even the nurses I was working with that day acknowledged that it’s hard for them to run to every alarm when often times it’s nothing. But it’s not always nothing.
In March of 2012 in Willow Grove, Pennsylvania, alarm fatigue caused the death of a young patient. ME was 17 years old, she was getting her tonsils removed in same day surgery center. She received the medication fentanyl after surgery and the staff failed to notice her change in respiratory status. Unfortunately, when they did notice, it was too late to save her. Due to her lack of oxygen, she suffered severe brain damage and she died 15 days later. The lawsuit states that the alarms were muted, therefor not properly alerting the nurses of her change in condition (Teen’s death, $6million settlement put the spotlight on alarm fatigue, 2013). There were important changes made after this event, but a patient was harmed by a known problem that wasn’t addressed.
There also should be a discussion about the number of alarms that sound every day. We don’t get alarm fatigue because they are few and far between, alarm fatigue happens when the alarms are constantly going off. In a dissertation by Colleen Lindell, she found that hospitals with fewer alarms per day had much quicker response times and fewer reports of alarm-related patient events (2018). An alarm-reduction policy was implemented in this hospital and it was shown to reduce fatigue, increase response time, and reduce patient harm (Lindell, 2018).
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How can it be improved? Implementing an alarm reduction policy seems to be a good place to start. Educating nurses on how to use technology properly as an assessment tool rather than a substitution can also improve patient outcomes. The percent of alarms that are actually “real” actionable alarms ranged from 36% to less than 1% (Hebda, Hunter, Czar, 2019). Not even half of the alarms are ones that need addressed on a good day. Unnecessary alarms ultimately cause what they’re intended to prevent.
Lindell, C. (2018). Medical Device Alarm Systems: A Multi-Hospital Stufy of Alarm-Related Events, Caregiver Alarm Response, and Their Contributing Factors. The Univeristy if Wisconsin- Milwaukee, ProQuest Dissertations Publishing, 181.
Hebda, T., Hunter, K. & Czar, P. (2019). Handbook of Informatics for Nurses & Healthcare Professionals 6th edition. Pearson. New York, NY.
Teen’s death, $6million settlement put the spotlight on alarm fatigue. (2013). Same-Day Surgery, 37(6).
Assignment: Distractors in our Environment
Assignment: Distractors in our Environment
Assignment: Distractors in our Environment
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Week 6 Discussion: Distractors in our Environments
The Universal Protocol is part of Joint Commission’s National Patient Safety Goals and this protocol is used to prevent wrong site, wrong surgery, and wrong-patient surgery. (The Universal Protocol, 2020) The surgical time-out is one of the three steps included in the protocol also including a pre-procedural verification and marking of the surgical site. Inadequate communication among healthcare providers is one of the root causes of sentinel events. This could be a miscommunication anywhere during the patient’s care. A sentinel event that involves wrong surgery, wrong site, or wrong patient surgery is one that is very preventable. This could be a career-ender or a confidence killer for a new or seasoned nurse because of the guilt that comes from such an event, not to mention the legal and financial cost to the nurse, surgeon, and hospital system. I have been working in surgery for a long time and I have seen these things happen. One nurse that had worked in my department for six years circulated an emergency surgery in which a wrong side craniotomy was performed. There was no consent since the unconscious patient came in alone by ambulance after a fall. The surgeon requested the patient be put in a prone position and the head was turned. The phone was ringing, machine alarms were going off, the surgical tech was setting up quickly and noisily, the anesthesia team was discussing their plan of care, and the nurse was standing with her patient. The prep was done, and the patient was draped before the surgeon entered the surgical suite. The CT scan was displayed in the room confirming the correct side of the subdural hematoma, but a time-out was not performed prior to incision. No one looked under the drapes to confirm the correct site and the wrong side of the skull was entered before the error was realized when no bleed was present. The nurse was so devastated that she resigned a few weeks later and now works in an office that only does local surgeries. This way her patients are awake and aware of what is happening and agree with what procedure is being performed. She is a great nurse, very caring, but she just did not trust herself and the system. It was in the middle of the night, an on-call case and she felt like it was all her fault even though there were four other people in the room. There are checks to prevent such sentinel events but since the surgeon didn’t mark the site, no one compared the site to the CT scan, no consent was filled out to compare against, a visual check didn’t happen before making an incision, and the surgical time-out was not performed it ended with a sentinel event.
Alarm fatigue can happen anywhere in a healthcare facility. In the OR, we have alarms and disruptions constantly with the anesthesia machines, O2 probes not reading, pagers going off, surgeon’s phones ringing, the constant noise of the suction, the whine of the cautery or drills, and best of all the surgeon’s music being played at a level that he can hear over all that noise. Alarm fatigue is defined as the desensitization of a healthcare provider to alarm stimulus that results from sensory overload which causes a delayed response to alarms or they can be missed altogether. (Abbott, 2014) All of these disruptions and alarms can cause providers to mentally block out certain noises without them even knowing it is happening. The patient’s needs are not being met or worse, a patient’s safety might be in peril if these alarms are not checked. Research shows 72% to 99% of all alarms have led to alarm fatigue but ignoring them can lead to medical mistakes. (Gaines, 2019) The Food and Drug Administration has reported that between 2005 and 2008 there were 560 alarm-related deaths in the United States. (Gaines, 2019) In 2013, The Joint Commission (TJC) issued an alert on alarms and made alarm management one of the National Patient Safety Goals starting in 2014. TJC continues to encourage healthcare systems to put policies in place to decrease the burden of unnecessary alarms and education for staff about the proper operation of alarm systems. (Gaines, 2019)
Week 6 discussion Distractors in our Environment Distractions are everywhere. They may include cellphones, the alarms sounding for multiple different reasons, overhead paging, monitors beeping, and staff interrupting our thoughts. Give an example of an ethical or legal issue that may arise if a patient has a poor outcome or sentinel event because of a distraction such as alarm fatigue. What does evidence reveal about alarm fatigue and distraction when it comes to patient safety? Week 7 discussion Use of Personal Communication Devices in Patient Care Settings How can the use of the nurse’s personal communication device(s) impact patient care positively and/or negatively? What are the ethical and legal implications? What does the professional literature say about how communication devices can support safe nursing practice? Week 8 discussion Reflective and Projected Practice Prior to posting, complete the Week 8 AACN Essentials Self-Assessment (Links to an external site.)Links to an external site.. Compare your scores from Week 1 to Week 8. How far have you come? How will you use evidence to further improve your nursing informatics knowledge during the next two years of practice? Week 2 Patient Guide Patient Education Technology Purpose The purpose of this assignment is to demonstrate the skills of the professional nurse as an educator. You are to prepare a guide that will serve as a handout to assist a specific patient that you identify. Your guide or handout should help this patient find and evaluate a reliable mobile health, or mHealth application (app) that is already developed. This may be related to his or her disease process or diagnosis, or may be an app that can help a patient maintain or improve good health, and prevent illness. You will develop the guide using Microsoft PowerPoint. PowerPoint is a versatile application that lets you design slideshows and handouts. For this assignment, you will be using PowerPoint to create a guide or handout that you may print and give to patients and families. You will be submitting this PowerPoint file for grading. Course Outcomes This assignment enables the student to meet the following Course Outcome. CO#1: Describe patient-care technologies as appropriate to address the needs of a diverse patient population. (PO#1) CO#5: Identify patient care technologies, information systems, and communication devices that support safe nursing practice. (PO#5) Points This assignment is worth a total of 175 points. Due Date The Patient Education Technology Guide to a Mobile Health Application PowerPoint assignment is due at the end of Week 2. Submit your completed assignment by Sunday; 11:59 p.m. MT. You may consult the Policies, under the Instruction & Resources Module, for details regarding late assignments. Late assignments will result in loss of points. Post questions about this assignment in the Q & A discussion. Directions Use Microsoft PowerPoint to create slides, which will be the basis of the guide or handout. You are required to cite your source(s) as it relates to your application slide. Other citations are permitted, but this is not a requirement for the assignment. Title slide (first slide): Include a title slide with your name and title of the presentation. Scenario Slide (one slide): This slide should include a brief scenario, then identify a patient who is experiencing a specific disease process or diagnosis who would benefit from an already developed and reliable mHealth app. Or, identify a person is currently healthy and would like to maintain or improve health and prevent illness. Be sure to include the nurse’s assessment of the patient’s learning needs and readiness to learn. Be specific. Example: Scenario for Ms. Ellis Jane Doe (your name here) Jennifer Ellis, a 62-year-old African American who has been recently diagnosed with chronic kidney disease (CKD). She has been prescribed several medications she must take every day. The nephrologist has stressed the importance of leading a healthy life style to slow or stop the progression of CKD. She is interested in ways in which she can better track her health and make healthier choices. She is a high school graduate and iPhone user, mostly to send text messages to family and friends. She is eager to learn how to use an app that can help her manager her CKD. Prepare the following slides as if you are presenting them to the patient. mHealth Application Slide (one to three slides): Identify a developed and reliable mHealth app that could benefit the patient. Describe the app including its: Name Purpose Intended audience Mobile device(s) upon which it will operate Where to download or obtain it. Include a working link if it is to be downloaded from a website. And any other information you believe would be pertinent to this situation. Sources that are used are cited. Teaching Slides (one to three slides): Prepare slides that contain important points about the app that you want to teach to the patient such as: how to use the app safely and effectively including how to interpret and act on the information that is provided. Evaluation Slide (one to three slides): Describe how you would determine the success of the patient’s use of this app. For example, include ways to evaluate the effectiveness of the teaching plan that are a good fit for the type of app or focus on specific ways that this app benefits the patient’s health and wellness. References (last slide): List any references for sources that were used or cited in the presentation. Writing and Design: There should be no spelling or grammatical errors. Writing is concise and clear. Avoid words that the patient may not understand. Slides are visually appealing incorporating graphics, photographs, colors, and themes. Review the section on Academic Integrity Policy found in the RNBSN Policies. All work must be original (in your own words) unless properly cited. Best Practices in Preparing PowerPoint Slideshows Be creative, but realistic. Incorporate graphics, color, themes, or photographs to increase interest. Make easy to read with short bullet points and large font. Review directions thoroughly. Cite all sources within the slides with (author, year) as well as on the Reference slide. Proofread prior to final submission. Spell check for spelling and grammar errors prior to final submission. Abide by the Chamberlain academic integrity policy. Tutorial: For those not familiar with the development of a PowerPoint slideshow, the following link to the Microsoft website may be helpful. http://office.microsoft.com/en-us/support/training-FX101782702.aspx (Links to an external site.)Links to an external site. The Chamberlain Student Success Strategies (CCSSS) offers a module on Computer Literacy that contains a section on PowerPoint. The link to SSP CCSSS may be found in your student portal. Week 4: Information Systems Paper
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