In the May 2013 Editor’s Note, I briefly touched upon an initiative by The Joint Commission to combat alarm fatigue in the hospital. As I subsequently learned at a session hosted by the Association for the Advancement of Medical Instrumentation (AAMI) earlier this month, The Joint Commission will be making the management of alarms one of their top priorities in 2014.
That means that in the coming year or two, you can expect to hear increasingly frequent conversation and directives involving alarm management. The way you interact with equipment and alarms will almost certainly change as a result.
At the AAMI session, a Joint Commission representative, George Mills, outlined the timing for the group’s new National Patient Safety Goal (NPSG) on alarm management. Though it is not yet official, Mills expects it to be approved by the end of summer; the first elements of the goal will take effect on January 1, 2014. The NPSG will ultimately require making alarm safety a hospital priority, mandating an annual inventory of alarms and review of alarm settings and the establishment of policies and procedures for alarm management.
Mills explained the impetus of the NPSG as the need to combat what he called “normalized deviance” with regard to alarms in clinical settings. As an example of the phenomenon, he described the case of a nurse working the third shift at a hospital who tried to help a patient sleep by silencing all the alarms. When she saw how well the patient slept as a result, she not only continued to turn off the alarms at night for this patient, but did so for other patients as well. Her deviation from the norm of alarms being on became her normal practice.
Ultimately, of course, that deviation from the norm led to disaster. As Mills told the story, one day she was called away from the hospital by a family emergency and neglected to restore the alarm settings. Later that day, one of her patients “coded” and died because the alarms were off.
Such normalized deviance is not a reflection of individual error as much as a response to a highly problematic system. That’s one reason why alarm hazards have been at or near the top of the ECRI Institute’s top 10 health technology hazards for the last 4 years in a row. (You can find ECRI’s reports and much more information about alarm management at the Alarm Safety Resource Site at www.ecri.org.)
As the Institute puts it, “the potential for alarm-related incidents leading to patient harm exists every minute of every day in virtually all healthcare facilities.” Though the risks can never be eliminated, “what healthcare facilities can do, however, is continuously improve the manner in which alarms are managed.”
That is The Joint Commission’s motivation for the forthcoming NPSG: to ensure that hospitals develop comprehensive approaches to alarm management. They will be required to address an array of issues including whether specific alarms are needed, when alarms can be disabled, when alarm parameters can be changed, who is authorized to disable or change alarms, how alarms will be monitored, and what systems will be in place to check individual alarms for accuracy and detectability.
Hospitals will not be required to have the new alarm management policies and procedures in place until the beginning of 2015. But for individual practitioners, the time to start thinking about alarm management and discussing it with colleagues is now. RT
John Bethune is the editorial director for RT Magazine. He can be reached at [email protected].