Recently, ECRI Institute released its Top Ten Technology Hazards for 2018. The purpose behind ECRI’s yearly list is to promote the safer use of technology:
The safe use of health technology—from beds and stretchers to large, complex imaging systems—requires identifying possible sources of danger or difficulty with those technologies and taking steps to minimize the likelihood that adverse events will occur. This list will help healthcare facilities do that.
Number 4 on this list deals with how Missed Alarms May Result from Inappropriately Configured Secondary Notification Devices and Systems:
Written by James Welch, CEO Arc Biomedical Consultants (firstname.lastname@example.org)
Mr. Welch is a Clinical Engineer with 17 yrs experience in hospitals and over 24 yrs as an executive in the medical device industry. His focus has been on applying technologies to improve patient safety through continuous surveillance monitoring. Mr. Welch has ten patents and articles in the field of wireless physiologic monitoring, surveillance systems and alarm management. He regularly contributes to the AAMI Foundation on alarm safety and is a voting member on a number of International Standards committees.
Early detection of physiologic deterioration is essential in improving patient safety in acute care hospital settings. Patients in non-ICU settings who are recovering from surgery or special procedures are especially vulnerable because of private or semi-private room settings prevents direct observation and nurse to patient ratios are often 1:6. Experts in Rapid Response Systems (RRS) have arrived at a consensus that strengthening early detection through continuous monitoring is essential in improving the effectiveness of RRS but only if such systems do not impose a burden on the clinical staff. The high incidence of nuisance alarms and cost are two of the major barriers preventing broader adoption of continuous monitoring on the general care floor. Read More
In PPAHS’ latest podcast, we spoke with Thomas W. Frederickson, MD, FACP, SFHM, MBA – lead author of the Society of Hospital Medicine RADEO guide (“Reducing Adverse Drug Events Related to Opioids”). The RADEO guide is a comprehensive clinician manual created with the aim to decrease opioid-related adverse events in an inpatient setting. Read More
by Mario Cattabiani (Director of Communications at Ross Feller Casey, LLP in Philadelphia)
Surgery can be a scary thing for any patient. Whether it is a minor procedure or life-saving necessity, all types of surgical procedures come with some degree of risk. To help ease your fears, it is a natural reaction to want to learn about everything that is going to happen during the procedure. You probably want to find out exactly what you need to do beforehand, what type of procedure is planned, who will be performing it, what the recovery will be like and when will you be able to go home. While all of these concerns and questions are completely valid, an important aspect of the process is left out.
Did you know that the first few hours after a surgical procedure are often just as risky as the actual operation? Just because you make it out of the operating room does not necessarily mean that you are in the clear just yet. While that can be a terrifying thought to come to grips with, it is the reality. Read More
Two patient deaths – one from alarm fatigue and one from a blood clot – make us stop and ask, “Are we doing enough to prevent patient deaths?
Death from Blood Clots
The Evening Post recently reported:
A teenage mother-to-be and her unborn baby were tragically killed by a DVT blood clot – just hours after finding out she was expecting a healthy boy.
Scarlett Holyoake, 18, was six months pregnant when she suddenly died from deep vein thrombosis after collapsing in her home.
In a recent Wall Street Journal article, “At the Hospital, Better Responses to Those Beeping Alarms”, actions that hospitals are taking to help solve alarm fatigue are noted.
Hats off to @JackiOBrien1, @Nada44880470, @pfcryer, @BEastman_Sazan, @aimee_jungman, and many others for their tweets about alarm fatigue.
Here are key examples:
The Joint Commission (TJC) has made better alarm management a national patient safety goal. In Sentinel Event Alert #50 “Medical device alarm safety in hospitals”, TJC has stated:
Will your hospital be compliant with The Joint Commission’s National Patient Safety Goal? In issuing this Goal, The Joint Commission stated:
In Phase II (beginning January 2016), hospitals will be expected to develop and implement specific components of policies and procedures. Education of those in the organization about alarm system management will also be required in January 2016.
The top 5 health and safety posts for 2015 on the Physician-Patient Alliance for Health & Safety (PPAHS) blog demonstrate risk management concerns for monitoring patients to prevent respiratory depression, preventing blood clots, and the need to manage device alarms.
By Sean Power
November 11, 2015
How many telemetry alarms are generated in a single month by two hospitals, 716 beds, 36,386 admissions, 93,634 visits to the emergency department, 3,418 births, 453 open-heart surgeries, and 11,688 surgical procedures?
Over a quarter million, according to Kevin Smith, BSN, RN, CNML, CVRN-BC, Director II Cardiac Telemetry Services at NCH Healthcare System in Naples, Florida, in a presentation shared at the Association for the Advancement of Medical Instrumentation Foundation’s (AAMI) Patient Safety Seminar.