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STRATEGIES TO IMPROVE MONITOR ALARM SAFETY

© 2011 ECRI INSTITUTE, 5200 BUTLER PIKE, PLYMOUTH MEETING, PA 19462-1298

Alarm Management is Complex

Care Model

Culture

Ancillary Technology Architectural

Layout

Technology Capabilities & Configuration

Alarm Coverage

Model

Staffing Patterns

Patient Population

Delineation of Responsibility

1. Assemble a multidisciplinary team

2. Review recent events and near misses

3. Observe alarm coverage processes and ask nurses and other staff about their concerns

4. Review entire alarm coverage system

5. Identify patient safety vulnerabilities and potential failures

6. Develop realistic, implementable strategies to address underlying causes

z Administrative sponsor (e.g., CNO, VP Quality)

z Key medical staff

z Nurse managers z Front-line nurses z Monitor technicians

z Patient safety/risk manager

z Clinical engineering staff

z IT staff z Consult with others, as appropriate

z Root causes z Frequency of alarm types

z Aggregate of alarm types per care area/shift

z Review remediation/results z Trends

z Routine rounding z Listen to staff concerns/problems

z Map processes for alarm notification and response

z Identify obvious problems z Excessive alarms z Difficulty in hearing alarms

z Delayed alarm response

z Pagers not being worn

z Culture z Infrastructure z Practices z Technology

z Delayed alarm response z Transport Communication Breakdown z Leads-off Apathy z Alarm Fatigue

z Proper skin prep z Proper electrode placement z Routine change of electrodes z Battery replacement every 24 hours z Elevate “Leads-Off Alarms” to crisis priority

FAILURES

TODAY FIXES

z Diffuse responsibility for alarm response z Competing priorities z Assumptions that someone else will respond z Excessive nuisance alarms

z Delineate responsibility for alarm response z Develop a back-up plan with tiers of coverage z Delineate responsibility for back-up response z Implement two-way communication devices

that would allow a nurse to request help z Develop an alarm escalation scheme

| Who receives initial alarm notification for each type of alarm

| Who receives back-up alarm notification for each type of alarm

| Time intervals per escalation

CAUSES

THINGS TO CONSIDER