Feb 23, 2024 NR 361 Week 6: Distractors in Our Environments
NR 361 Week 6: Distractors in Our Environments
Week 6 Discussion Post:
When I imagine a hospital, I picture bright white lights in the halls and patient rooms, the smell of Clorox wipes or germicidal wipes, and then the sound of never-ending beeping alarms. Even my patients have complained about the sound IV pumps make when alarming about downstream or upstream occlusions, or when an infusion is complete. I do believe alarms are useful in preventing harm to patients. In my time as a nurse, I have noticed many situations in which alarm fatigue or lack of alarms has caused poor outcomes for patients. One example that comes to mind, is when a patient who appeared to be medically stable, suffered an Anterior ST segment elevation myocardial infarction. The patient’s telemetry monitor did not alarm to the change in heart rhythm. The patient used the call light to ask for help because he became symptomatic of the MI he was experiencing. Upon review of the telemetry strips, the patient’s ST segment had changed for 12 minutes before the patient called for help. The patient did unfortunately pass away, but there were no legal repercussions since the patient’s death was not due to negligence. Had the telemetry monitor alarmed, and been silenced by a medical professional, then that would be considered negligence. This death took a toll on all of the healthcare team members including the physicians, nurses, CNAs, and telemetry technicians involved. At our hospital, the telemetry monitors have the same constant alarm sound for VTACH as for when the patient’s oxygen saturation decreases. The same rhythmic alarm sounds when a lead has been removed as when the monitor detects a PVC. Our textbook mentions how a nurse may experience alarm fatigue during their shift because of the high number of potential false alarms they hear (Hebda, Hunter, & Czar, 2019, p.12). I believe the solution to alarm fatigue is to change the sounds made by these alarms for different kinds of alerts. A deadly cardiac rhythm such as VTACH or severe bradycardia should have distinctly different alarm sound than the alert for an oxygen saturation of 88%, especially if the patient has COPD or another disease that may cause the patient to have consistently low oxygen saturations. According to the article, Alarm fatigue a top patient safety hazard, “85%-90% of alerts are false or nuisance alarms, indicating conditions that don’t require clinical interventions” (Jones, 2014, p. 178). In my opinion, 1 single PVC should not warrant a sound alarm, but it should show a visual alarm. Changing alarm sounds and tones may also be useful, such as verbal commands or different sounds for critical alerts vs routine alerts.
References
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.
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Jones K. (2014). Alarm fatigue a top patient safety hazard. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 186(3), 178. https://doi.org/10.1503/cmaj.109-4696
NR 361 Week 6: Distractors in Our Environments
“Preventing harm to patients while providing their care continues to be a complex and costly understating for any hospital or healthcare system.” (Kai & Lipschultz. 2015). We as nurses are constantly trying to maintain the best care and sometimes under very stressful situations. We may be assisting a patient to the bathroom while another patient’s bedside alarm is going off. This is not always the case, but it happens frequently. At times nurses do not feel that the alarms mean anything and will ignore them for a period of time assuming that it is a patient asking for a glass of water or wanting to ask a question. This is not an excuse to condone the reaction, but an observation of being a nurse for many years. Some departments that have alarms and they all sound similar. The IV alarm, feeding pumps, bed alarms and call lights all can have similar sounds in some areas of the hospital, and this can create confusion as to the importance of the alarm. Alarm fatigue can be caused by the amount of alarms in the care setting. “This alarm fatigue is compounded by the number of potential false alarms during a nurses’ work shift.” (Hebda, Hunter & Czar. 2019). When alarms go unanswered then serious consequences could happen for the patient, nurse and facility. A patient may fall and be injured from ignoring a bed alarm. Another patient’s cardiac alarm may have went off 4 or 5 times and the nurse sees that the patient is fine and decides that it must be malfunctioning and decides to ignore the next alarm and the patient could be in cardiac arrest. Many issues arise from too many or false alarms.
Improvement could be to reduce the number of alarms within the care setting. I have a big thing about call lights sounding. I would like to see the implementation of an intercom system from a patient’s room to the desk. This way there is not another sound going off in the hallways and the patient just speaks their needs right to the desk and then they can immediately triage the need. If a patient needs assistance to the restroom we know that takes precedence over someone needing a cup of coffee. Patients that need assistance to the restroom need attention first before they attempt on their own. IV’s need monitored through a different system so we can see if the alarm is due to air in the line or if it is because the medication is done infusing. Bed alarms should have a very specific alarm so that we know a patient may have fallen is attempting to get out of bed on their own and they are a fall risk.
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses and healthcare professionals (6th ed.). Pearson.
Kai, S., & Lipschultz, A. (2015). Patient safety and healthcare technology management. Biomedical Instrumentation & Technology, 49 (1), 60-65. Retrieved from: https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=25621652&site=eds-live&scope=siteLinks to an external site.
“Preventing harm to patients while providing their care continues to be a complex and costly understating for any hospital or healthcare system.” (Kai & Lipschultz. 2015). We as nurses are constantly trying to maintain the best care and sometimes under very stressful situations. We may be assisting a patient to the bathroom while another patient’s bedside alarm is going off. This is not always the case, but it happens frequently. At times nurses do not feel that the alarms mean anything and will ignore them for a period of time assuming that it is a patient asking for a glass of water or wanting to ask a question. This is not an excuse to condone the reaction, but an observation of being a nurse for many years. Some departments that have alarms and they all sound similar. The IV alarm, feeding pumps, bed alarms and call lights all can have similar sounds in some areas of the hospital, and this can create confusion as to the importance of the alarm. Alarm fatigue can be caused by the amount of alarms in the care setting. “This alarm fatigue is compounded by the number of potential false alarms during a nurses’ work shift.” (Hebda, Hunter & Czar. 2019). When alarms go unanswered then serious consequences could happen for the patient, nurse and facility. A patient may fall and be injured from ignoring a bed alarm. Another patient’s cardiac alarm may have went off 4 or 5 times and the nurse sees that the patient is fine and decides that it must be malfunctioning and decides to ignore the next alarm and the patient could be in cardiac arrest. Many issues arise from too many or false alarms.
Improvement could be to reduce the number of alarms within the care setting. I have a big thing about call lights sounding. I would like to see the implementation of an intercom system from a patient’s room to the desk. This way there is not another sound going off in the hallways and the patient just speaks their needs right to the desk and then they can immediately triage the need. If a patient needs assistance to the restroom we know that takes precedence over someone needing a cup of coffee. Patients that need assistance to the restroom need attention first before they attempt on their own. IV’s need monitored through a different system so we can see if the alarm is due to air in the line or if it is because the medication is done infusing. Bed alarms should have a very specific alarm so that we know a patient may have fallen is attempting to get out of bed on their own and they are a fall risk.
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses and healthcare professionals (6th ed.). Pearson.
Kai, S., & Lipschultz, A. (2015). Patient safety and healthcare technology management. Biomedical Instrumentation & Technology, 49 (1), 60-65. Retrieved from: https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=25621652&site=eds-live&scope=siteLinks to an external site.
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Distractions are everywhere. They may include cellphones, multiple alarms sounding, overhead paging, monitors beeping, and various interruptions that disrupt your train of thought.
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?
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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).
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).
Also Check Out: NR 361 Week 7: Use of Personal Communication Devices in Patient Care Settings
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