There is uniform agreement that alarm fatigue is a major problem. Alarm systems are built into many medical devices, such as infusion pumps and ventilators. When they work as intended, they alert caregivers that a decision or action is required for the patient’s health and safety. However, too many alarms, including false alarms, can fatigue, confuse, and overload clinicians.

Dr. Paul M. Schyve, Senior Advisor, Healthcare Improvement, The Joint Commission

We need to do a better job of explaining how alarms work and what to expect if they go off.

Dr. Steven D. Hanks, Executive Vice-President and Chief Medical Officer for the Hospital of Central Connecticut

Medical device manufacturers are developing smarter alarm systems that can indicate when a patient is trending in a certain direction.

James Keller, Vice-President of Health Technology Evaluation and Safety, ECRI Institute

Alarm fatigue is a national problem. Excessive false alarms occur frequently and contribute to alarm desensitization, mistrust, and lack of caregiver response. This may lead to staff disabling or ignoring alarm systems, which decreases patient safety.

Maria Cvach, MS, RN, CCRN, Assistant Director of Nursing, Clinical Standards, The Johns Hopkins Hospital

The value of medical checklists lies in their concise consolidation of a considered body of knowledge in one simple document.

Eric Coleman, MD, Professor of Geriatric Medicine and Director of the Care Transitions Program at the University of Colorado

The use of a well-constructed checklist that ensures proper procedures are followed in patient-controlled analgesia would enhance patient safety.

Dr. Andrew Kofke, Co-Director Hospital of the University of Pennsylvania Neurocritical Care Program

A checklist would help avoid many things that could go wrong with PCA.

Dr. Elliot Krane, Director, Pediatric Pain Management, Lucile Packard Children’s Hospital at Stanford

In practice, checklists serve as a mental reminder of critical steps that we may or may not remember. Therefore, the value of a checklist with regards to PCAs would be to remind us/double check a critical step in the process.

Dr. Julius Cuong Pham, Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine

Use and adherence with standardized processes for eligible patients leads to better clinical outcomes. The PPAHS PCA checklist lays out essential steps to be taken to initiate patient-controlled analgesia (PCA) with a patient and to continue to assess that patient’s use of PCA. Following these steps will help to increase patient safety and save lives.

Frank Federico, RPh, Patient Safety Advisory Group at The Joint Commission and executive director at the Institute for Healthcare Improvement

In my opinion, the solutions lie closer to the bedside. For example, real-time monitoring has benefits beyond simple patient monitoring. For the nurses in our study, the major revelation was that their patients had changed and that they needed to be doing things differently. Continuous electronic monitoring gave them feedback about the effectiveness of their actions on these patients.

Anne Miller, RN, Assistant Professor at Center for Research and Innovation in Systems Safety at Vanderbilt University Medical Center

We have previously recommended the development of an action plan to implement effective physiological monitoring of patients on PCA therapy. As such, I would concur with the VHA recommendations on this [to use PCA pumps with integrated capnography].

David Watson, VP, ECRI Institute

A misunderstanding on the part of nurses that if a PCA pump is ordered and the patient can receive, for example, half of a milligram of Morphine every hour that the patient cannot develop respiratory depression if the order is followed and the pump is setup correctly. That is certainly not true because of the variables, the other medications, or the way the patient is clearing anesthesia out of her body after surgery. You can still end up with respiratory depression even if the instructions are followed on the pump.

Pat Iyer, MSN, RN, LNCC, President, Avoid Medical Errors

For pregnant women, the risk of VTE is 4-5 times higher than women who are not pregnant. Moreover, this risk is at least twice as much following cesarean delivery.

Dr. Andra James, Professor of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Virginia School of Medicine

While PCA may be the safest mode of opioid delivery it is true that regardless of the route of administration, respiratory depression may still occur. To help prevent such incidents from happening, it should be remembered that some of the most significant strides in medicine and surgery are directly attributable to anesthesiology’s advances in patient monitoring.

Dr. Jason McKeown, Associate Professor, Medical Director – Inpatient Pain Service, University of Alabama School of Medicine

One reason why it is not effective is that a ‘periodic check’ and pulse oximetry would only catch an error, not prevent the error.

Matthew Grissinger, Director, Error Reporting Programs at Institute for Safe Medication Practices

As a practicing anesthesiologist, I believe that spot-checking oxygen saturation is not sufficient.

Elana B. Lubit, NYU School of Medicine

Monitoring only SPO2 does not assess adequacy of oxygenation, especially in patients receiving oxygen post op. Also, check q 2.5 hours allow too long a time for hypoxic brain damage to occur…continuous monitoring of ETCO2 and respiratory rate must be added.

E Frost, Icahn Medical Center at Mount Sinai

The conclusions and recommendations of APSF are that intermittent ‘spot checks’ of oxygenation (pulse oximetry) and ventilation (nursing assessment) are not adequate for reliably recognizing clinically significant evolving drug-induced respiratory depression in the postoperative period. For the CMS measure to better ensure patient safety, APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.

Robert Stoelting, MD, President of the Anesthesia Patient Safety Foundation

Spot checks of SpO2, as are commonly taken on med/surg floors, need to be eliminated from patient monitoring practice because these single measurements may mislead a provider into thinking the patient is fine when in fact they may be close to the precipice of unrecoverable respiratory depression. Entering a patient room and placing a pulse oximeter on their finger stimulates their consciousness and respiration sufficiently to falsely elevate their reading, particularly when they are receive supplemental oxygen. Once the provider leaves the room, this stimulus fades and the patient may lapse back into a dangerous level of respiratory narcosis.

Dr. Frank Overdyk, Executive Director for Research, North American Partners in Anesthesiology, and Professor of Anesthesiology at Hofstra North Shore-LIJ School of Medicine

One action that VHA has taken to address this high error incident rate is to use a PCA pump that has an integrated end tidal CO2 monitor or capnograph. A capnograph measures in real-time the adequacy of ventilation. Using this technology could prevent more than 60 percent of adverse events related to PCA pumps.

“In addition, we developed a standard protocol that looks at the other key issues that need to be addressed for safe use of PCA pumps: human factors (communication, training, fatigue and scheduling); the environment and equipment, rules, policies and procedures, and barriers and controls.

Bryanne Patail, Biomedical Engineer at the U.S. Department of Veterans Affairs, National Center for Patient Safety

We have a healthcare system that relies on the heroism of our clinicians rather than designing safe systems. There is technology right now that can monitor someone.

Dr. Peter Pronovost, PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient Care

Monitoring patients for how much carbon dioxide they are breathing out with capnography provides us with the earliest possible indicator to detect the onset of opioid-induced respiratory depression. Continuously electronically monitoring with capnography will save lives.

Dr. Cheryl Wibbens, Chief Medical Officer at Memorial Hospital

“The Joint Commission recognizes there is an opportunity to improve care for patients by improving the safety of opioid use in acute care settings given that data show opioids are among the top three drugs in which medication-related adverse events are reported. Opioids are necessary to prevent suffering, but there are risks related to potency, route of administration, and patient history. By engaging in a comprehensive approach to assessment, monitoring, and patient education, opioid overuse and associated harm can be prevented.”

Ana Pujols McKee, MD,Executive Vice President and Chief Medical Officer at The Joint Commission

PCA errors certainly occur, both in programming and in delivery, but any published estimate is likely to be only the tip of the iceberg.

Dr. Richard Dutton, Executive Director of the Anesthesia Quality Institute
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