Would You Blame This RN or Look Deeper?

This article discusses the importance of emotional intelligence and assertiveness for nurses and the relevance that self-care has to patient safety. Nurses Announcements Archive Article

Would You Blame This RN or Look Deeper?

In this compelling Ted Talk, Leilani Schweitzer, tells us about the death of her little boy, Gabriel after a series of medical mistakes. He was 20 months old when his heart stopped while hospitalized.

All of the alarms that he was hooked up to had been turned off by a nurse with devastating results. Although this happened more than 10 years ago, much can be learned from this. (If you can, please find 15 minutes to listen to her TED Talk.)

[video=youtube_share;qmaY9DEzBzI]

Leilani is articulate and despite unimaginable emotional pain does not blame the nurse. She understands, at least to some extent that this was a systems failure and has a compelling message about the importance of three components of medicine:

  • Transparency
  • Compassion
  • Truth

In this case, all three were utilized in one of the two hospitals involved in Gabriel's death and contributed to quality improvements in the alarm design and some healing for this Mom. I also see a fourth and somewhat elusive component: the need for emotional intelligence (EQ) for nurses. Not only so that nurses will speak-up as patient advocates, but for themselves and their colleagues too!

In this case, how does a highly trained professional get to the point where she would do something that appears so egregious? Part of the answer lies in having the self-awareness and self-respect to say:

  • I'm having a hard time thinking with all of these alarms and interruptions.
  • I'm too tired to work overtime.
  • I need help. and ultimately: We need help.

Or to have a colleague say:

  • You look exhausted!
  • It is hard for me to concentrate with all these interruptions too!
  • What can I do to help?

Or to have a manager say:

  • [to staff] Let's see what we can do to address the frequency of alarms on the unit.
  • [to senior leaders] We need to consider technical and staffing solutions to address the frequency of alarms distracting our frontline staff.

All of these arise out of a respect for 'self'' and 'others' that is critical for patient safety and for sustaining long-term rewarding careers. Nurses must be able to set healthy limits, to have these limits respected, and to work in cultures where respect is the norm.

It would be easy to be aghast at the nurse's action. Who could justify turning off an alarm, not just at the bedside, but the nurses' station too? She shouldn't have. That's obvious. But seeking to understand the individual and organizational factors that contributed. Did she have alarm fatigue? Was there a history of false alarms with this and other patients. That shift? That day? That unit? Was understaffing contributing to excessive interruptions and distractions? Was this nurse on chronic 'overload'?

Understanding how unnecessary interruptions, such as false alarms or alarms that are in place as a substitution for adequate staffing is hard to quantify yet there effect can have a profound impact on our ability to concentrate.

Over the last decade there has been an increased focus on training nurses in assertiveness. Yet available models such as TEAMSTEPS, SBAR or ISBAR focus on speaking up to physicians and others for patients. This is only part of building true assertiveness and I advocate for a deeper process that involves emotional intelligence. A process that medical improv is perfectly suited for and where nurses develop self-awareness self-respect, and respect for others, including colleagues. I don't think we can optimize safe care build safe cultures, or sustain longterm, rewarding careers without it. What do you think?

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BethBoynton

About BethBoynton

Beth Boynton, RN, MS is the author of “Successful Nurse Communication: Safe Care, Healthy Workplaces & Rewarding Careers”. She’s been teaching healthcare professionals about communication, collaboration, and culture for a decade and is excited about using ‘Medical Improv’ as a fun and powerful way to develop these skills and promote healthy workplaces. Well known for her blog “Confident Voices in Healthcare” Blog and youtube, Interruption Awareness: A Nursing Minute for Patient Safety, she and can be reached at beth@ bethboynton.com or www.confidentvoices.com.

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I am unclear on what to think. No nurse at any time should be shutting off alarms on critical or unstable patients.

Part of the job is to monitor, with tunnel vision sometimes. However, nurses can't be everywhere at once. So if multiple alarms are going off simultaneously, a nurse can't respond to all of them in a like manner.

With that being said, the answer is not to just turn them off and ignore the possibility of a significantly poor outcome.

Noise fatigue, alarm fatigue--whatever you would like to call it, the fact remains that warning alarms are what keeps patient's alive. It is a part of nursing practice.

An acuity based staffing system would certainly be a better solution. More than 2 nurses on a critical floor on nights would also be ideal (and I know there are some units that have more, but often not). Hard and fast rules on patient loads across the board is also something that needs to happen.

When healthcare became big business it took away the very essence of why there's a business to begin with. Patients who can expect a prompt professional level of care. All dollars, no sense.

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Specializes in Nephrology, Cardiology, ER, ICU.

This was a very sad situation for all concerned.

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I, too, am not sure what to think. I'm a big fan of the "systems problem/systems solution" approach to improving the workplace but, at the same time, there's no excuse for turning off the alarms on a critically ill child and leaving them off. Yes, a better answer would have been for the nurse to have asked for help and gotten it, but, IMO, there's got to be more accountability than saying we need to build better workplaces. Nursing always wants to be taken seriously as professionals; well, a big part of being a professional is being accountable for and taking responsibility for your own practice and your own actions.

I guess my answer to the question that is the title of the thread is "Both." I don't see them as mutually exclusive options.

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Specializes in Healthcare risk management and liability.

I agree with elkpark. As a risk and patient safety manager, I am a big believer in the systems improvement approach. But there is also a place for individual accountability in a just culture model. I am not in favor of deliberately turning off or bypassing safety systems without a compelling reason to do so. That being said, a tragedy for all involved and my heart goes out to them.

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Specializes in ICU.

I'd blame the RN.

There is no excuse for turning alarms off altogether when you can always adjust the parameters instead. I spend a lot of time fiddling with the monitors to get the right settings for the patient every shift because I can't stand extraneous alarms. It really aggravates me when people don't customize the alarms to the patient. I will even say something to coworkers at neighboring pods if I can hear their alarms going off over and over again because it is just intolerable to have all of that noise happening all of the time, and with their permission, I will change their patients' parameters myself. There is nothing that contributes to alarm fatigue more than a whole ton of unnecessary alarms... but that's a reason to set smarter alarms, not to turn them off.

It's just especially mindblowing that a nurse would turn alarms off to let a patient family member sleep. If the family members are extremely bothered by the alarms in the room, I remind them that there are places to sleep in the waiting room, and it's just steps away from their loved one's room. I guess it's different when the patients are children, but I couldn't imagine making those kinds of allowances for a family member.

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Specializes in Healthcare risk management and liability.

As a side note, I have handled a couple of anesthesia cases due to anesthesia personnel turning off alarms. In these cases, the patient had poor outcomes, one case being an anoxic brain injury. From a liability perspective, there is really no defense to the claims, and the only question is how big of a check you have to write to settle the case. The anoxic brain injury case was a seven figure settlement.

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Specializes in Pediatrics, Emergency, Trauma.

I read this article and watched the video hours ago, and I finally returned to respond.

I HATE false alarms; they are the bane off existence.

I have dreamed about alarms since I have been a tech on a telemetry unit; I don't like false alarms, I don't like alarms especially when someone has decided to use a bathroom and play with the buttons; especially in our waiting room-just recently a kid pressed the alarm and then locked the bathroom; we had to get a nickel to unlock the door-and we hear it from one of our zones-it just sets off a series of events of no one knows where it's coming from, etc etc.

Despite my frustrations with alarms, I set alarms to the appropriate ranges and when alerted, assess the pt and then the monitor, whether it's alarming for v-tach because the kid pulled off his monitor and then the parent tried to put the leads on with a valiant effort.

I agree with jadelpn about how the business has stretched nurses so thin that they are blatantly ignoring the basic fact that they need us to provide prompt, quality care; more nursing staff can solve this problem; however, as elkpark pointed out accountability is at play also; even with more nursing staff, will a nurse blatantly turn off the alarms? Will a nurse waffle and turn them off to appease a parent and family member?

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Specializes in CCU.

There is not enough information provided. We know the alarms were turned off at the bedside but did the nurse understand the full impact? I find it hard to believe that she would deliberately turn them off. It sounded as if she was trying to silence them in the patient room. Did she know that this action stopped them for her pager and also the central monitor station? The monitor company agreed to a gap in safety because "they never thought anyone would go into 7 screens to try and turn off the alarms".

What kind of inservice/education did this nurse receive regarding these monitors?...was it an "inservice" while working, trying to answer call bells and take care of patients....how can we learn...yet administration feels it it more than appropriate.

Sad for all involved!

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Specializes in ER.

A pediatric unit I worked on had a central monitoring system, and if one child was alarming, the tones were the same as when two or three were alarming. So, if the 18 month old with ordered oximetry was playing with their family it was tempting, and probably safer for the unit, to turn off their alarms. I did that, and asked the parents to ring the buzzer when they were ready to leave so I could reset the alarms. They settled the child to sleep, and left without calling me. I went in to a child sleeping in a room alone with no monitor. Scared me badly, even though the child was fine, he had real potential to desat.

Should I have kept him on the monitor while he was up with his family? Even though the central alarm sounds would have been going continuously for a couple hours, and basically removed any audio cues for the other children. It's a no win, and management is perfectly aware.

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Specializes in Communication, Medical Improv.

Great points, Jadelpn. You help describe the catch 22 we get in when there are not enough people to answer all the alarms and I completely agree that an "acuity-based staffing system" would be a better and safer solution. Sometimes, I have felt that alarms are being used to minimize staffing and that has increased along with the "big business" mindset that has taken hold. Thank you for sharing your insights.

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Specializes in Communication, Medical Improv.

Thanks for your insights.....I'm a systems problem/systems solution thinker too and yet can't condone the RN's action either. I think it might be worth adding that in this instance, the RN and the bigger system are at fault, but if the RN is blamed and the organization fails to look deeper into the systems issues then I think there is or should be a greater responsibility on the part of leaders of the organization for future incidents. I don't think an RN can ever be blameless and that isn't my point, but rather to illuminate what many RNs may be up against in terms of asking for help or setting limits. Any Legal Nurse Consultants out there looking for patterns of organizational behavior or experience with culpability of leaders. Ultimately, we do have the responsibility to say "no" to working in an unsafe staffing situ....yet it is very complicated.

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