- 1Apr 3, '10 by newnurse66Have any of you seen or experiences alarm fatigue? I found this article interesting especially these days when the number of alarms just seems to be growing. I myself have witnessed (working on a busy medical floor) where alarms were going off, and if a nurse was not around nobody was checking on the patient.
ĎAlarm fatigueí linked to patientís death
US agency says monitors at MGH unheeded
By Liz Kowalczyk Globe Staff / April 3, 2010
Federal investigators concluded that ďalarm fatigueíí experienced by nurses working among constantly beeping monitors contributed to the death of a heart patient at Massachusetts General Hospital in January.
In a report released yesterday, the investigators said10 nurses on duty that morning could not recall hearing the beeps at the central nursesí station or seeing scrolling tickertape messages on three hallway signs that would have warned them as the patientís heart rate fell and finally stopped over a 20-minute span.
Additionally, federal investigators said the volume for a separate audible crisis alarm on the patientís bedside monitor was turned off the night before by an unknown person. Mass. General executives had previously told the Globe that this crisis alarm had been inadvertently turned off.
But investigators for the Centers for Medicare & Medicaid Services said that desensitization to alarms that actually sounded also was a factor in the patientís death.
Mass. General executives said yesterday thatthey have taken numerous steps to correct the problems, including disabling the off switches for alarms on bedside cardiac monitors and that the federal Medicare program approved the hospitalís plan for addressing the issues.
Federal inspectors reviewed the case as part of a random routine inspection at the hospital from Feb. 2 to Feb. 16. They found additional problems during the visit as well, including locating video screens where visitors could see patients who were being monitored in their rooms.
Patient safety officials across the country have said the heart patientís death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.
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- 2Apr 3, '10 by onetiredmommaMy experience has been that the "basic" alarms are often ignored but with the system we use critical alarms are much louder and significantly different enough to make every one jump and run. Recently I went from the end of the hall furtherest from the nurses station to turn off an alarm on my pt. When I walked into a full nurses station (5 nurses plus the secretary) the charge nurse, sitting closest to the monitor sighed and said "finally! thank-you!".
- 1Apr 3, '10 by Blackcat99I am so glad I am no longer working in LTC. It drove me crazy all of the non-stop alarms-wheelchair alarms, bed alarms, bathroom alarms, IV antibiotic alarms, feeding tube alarms etc. It always seemed that they all went off at the same time. It made me a nervous wreck.
- 3Apr 3, '10 by catshowladyI can see this happening. Our current telemetry system sends out frequent false alarms. We have red alarms (critical, like V-tach/fib/asystole) and yellow alarms (not so critical, like PVC's and the like). We have two frequent false red alarms. One is for "apnea" - it even alarms on pt's that are ventilated. Another is specific to pts with a paced rhythm - frequent "asystole" alarms when you can see from across the room that they are in a paced rhythm. You no more than silence these alarms and they go off again, and we just don't have the staff to have a monitor tech (or an RN!) constantly sitting there for a 15-bed unit. You *have* to ignore the alarms to a point if you have other work to do. I can see where if someone else alarmed for real on the same central monitor where we were having a problem false alarm, it could get ignored for several (potentially crucial) minutes.
On day shift, we get so many "yellow alarms" from the monitors that they often go ignored as well. Many are related to artifact on the SpO2 monitor, because pts are awake and doing things like eating, bathing, visiting, therapy, etc.
We also had a recent issue on another unit. On these units, the RN would get paged for every telemetry alarm, red or yellow. Apparently, someone was getting so many alarms that they quit checking the pager and very nearly missed a critical problem, resulting in a very close call for a pt. This led to changes in the way the alarms were paged out.
I try to be good about checking any alarm, whether it's the tele, IV, tube feed pump, SCD machine, whatever, but there are times when I am too behind in my own work to check on other nurses' pts. Unless it's a bed alarm or a red alarm on the telemetry, I don't always have time to check every single one. I'm only one person. I'm sure I'm not the first, nor will I be the last, nurse to be in that position.
- 8Apr 3, '10 by whipping girl in 07Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.
I'm not so sure it's "aggravating" so much as it's distracting, especially when the monitor picks up v-tach because your patient is brushing his teeth. How much time do we waste dealing with false alarms? It's like the boy who cried wolf!
Jeanette Ives Erickson, the hospital’s chief nurse, said yesterday that Mass. General has formed a committee that is reviewing the guidelines for placing patients on monitors in the first place, to see if it is possible to monitor fewer patients and thereby reduce noise and alarm fatigue.
Of course, it was a nurse who actually had an idea about how to fix the problem instead of just blaming the nurses who didn't hear the alarms. How many patients are on telemetry who really don't need to be? Is it really necessary to have non-cardiac patients on telemetry, or even cardiac patients on telemetry until they are discharged? My favorite is the doctor who puts the 93 year old DNR on telemetry! And then you are out of monitors for patients who really need them and have to call and try to get an order to discontinue telemetry on people who don't need it anymore.
- 2Apr 3, '10 by chaniAlarm fatique! you betcha! especially rhythm alarms. When I ring an ICU I can tell what ventilator they have by the sound of the alarm. When I was an educator I spent considerable time with newbies talking about the need to set realistic alarm settings and to respond quickly.
Additionally alarms are extremely distressing to relatives and are a significant source of noise pollution in ICU.
- 2Apr 4, '10 by TampaTechI know all about this. I am a monitor tech and have to watch 6 seperate screens with as many as 50 pt's. At 51 we then get 2 mon techs. Wecan watch a total of 74. With all those pts the alarms are going off ALL the time. I must admit I have become very adapted to alrams to the point they sometimes dont register with me.
- 1Apr 4, '10 by herring_RN GuideQuote from TampaTechThe position of the American College of Cardiology is, "There must be adequate human surveillance of the monitors 24 hours a day by medical, nursing or paramedical personnel (monitor watchers) trained and qualified in the ECG recognition of clinically significant cardiac rhythm disturbances."I know all about this. I am a monitor tech and have to watch 6 seperate screens with as many as 50 pt's. At 51 we then get 2 mon techs. Wecan watch a total of 74. With all those pts the alarms are going off ALL the time. I must admit I have become very adapted to alrams to the point they sometimes dont register with me.
50 patients is too many.
You should be able to notice when a pacemaker spike is not followed by a "T" wave or when a patint goes into atrial fibrillation. And to ensure that a nurse responds when you inform him or her of an arrythmia. Or even when the leads are off.
If th hospital can afford to buy monitoring equipment it can afford a monitor tech.
Otherwise why have it at all?
- 4Apr 5, '10 by luvRNsWow! Realy and ongoing risk for nurses who monitor. So how do we decrease the risk?
1. evaluate all monitored patients at shift change. Is monitoring still needed? What are their alarm settings?No just the highs and lows.... every alarm setting...
2. communicate with other members of the team ( peers, charge nurse, monitor tech, CNA's). Identify your concerns at beginning of shift, breaks and other hand off opportunities
3. Agressive false alarm management. For obese patients or patients with an increased A-P diameter ( COPD tpyes) cluster all five leads over the center of the chest. This diminishes artifact. Monitor in two leads ( most systems now do this automatically) Check the leads you are monitoring in, and use those with large R waves if possible.
4. Check/change electrodes as needed. Many monitor techs will tell you tihs is their main compaint with nursing staff . Their requests to do this are often not followed up on....
5. Default alarm set up. When choosing new equipment ASK about false alarm rates. Some products are better than others in this regard. Be an informed consumer if you have a say....
6. Default alarm set up ( contunied). When your new equipment is installed and configured, vendors will work with clinical and biomedical staff to set default alarms. Too many alarms set to default 'on'position can create the alarm fatigue mentioned in other posts here. Set realistic defaults. If you don't konw what those may be ask, the vendor what the usuals are or ask to speak to other product users.
7. Root cause analysis. If you do have an alarm failure ( even if not serious) examine the system you have in place. Failures are most often systems and no people-caused. What failed in this instance, and what can you all do to prevent the same or worse failure in the future?
There may be other actions or solutions; If anyone has more, please continue the list. This is an important topic