Walking tour could reveal problems with clinical alarms
Listen to experiences of frontline providers
A walking tour of each patient care area that includes clinical alarms could reveal both problems and solutions you might not otherwise consider, says Britton Berek, CCE, MBA, associate director of the standards interpretation group for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. He advises talking to both unit managers and frontline providers to hear their experiences.
These questions may be useful:
- Do they have any problems with the alarms on the units?
- Is any device known for having a finicky or malfunctioning alarm?
- What happens when the unit gets busy and loud?
- Have the nurses ever missed an alarm because they couldn’t hear it?
- Have they responded to the wrong patient because they misinterpreted where the alarm was coming from?
- Are doors typically left open or closed? Does that affect how well they can hear the alarms?
- Are there certain rooms or areas from which the nurses know alarms are difficult to hear?
- What happens if a nurse is tending to a patient on one end of the unit and an alarm goes off on the other end? Can it be heard?
- Does the night shift have any different concerns?
Clinical Alarms and Patient Safety Information Sources
- Emergency Care Research Institute. Critical alarms: Patients at risk. Health Devices 1996; 25(1):25-30.
- Emergency Care Research Institute. Evaluation of monitors. Health Devices 1999; 28(1 & 2):15-17.
- Emergency Care Research Institute. Hazard report: Mis-set ventilator alarms can be lethal. Health Devices 1999; 28(4):165-166.
- Emergency Care Research Institute. Eye on medical errors. Health Devices 2000; 29(5): 155.
- Medical College of Virginia. Ineffectiveness of alarming systems in the emergency department. Acad Emerg Med 2001; 8(5):572.
- Joint Commission on Accreditation of Healthcare Organizations. Preventing ventilator- related deaths and injuries. Sentinel Event Alert February 2002; Issue 25. Web site: www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_19.htm.
- Emergency Care Research Institute. Critical alarms and patient safety: ECRI’s guide to developing effective alarm strategies and responding to JCAHO’s alarm-safety goal. Health Devices, Special Issue, November 2002; 31(11). To order, go to: www.ecri.org/documents/112702.asp.
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