ADVANCING
YOUR PRACTICE
Alarming
monitor problems
By Kathleen M. Weil,
MS, BSN, RN
A patient on continuous
cardiac monitoring experienced ventricular fibrillation
and died without her monitor sounding or displaying
an alarm. The incident investigation demonstrated that
although the monitor had detected the problem, dysrhythmia
processing had been suspended. This meant that dysrhythmias
such as ventricular fibrillation, ventricular tachycardia,
and asystole wouldn't cause an alarm.
In a similar case, a patient
experienced ventricular fibrillation, but the monitor
didn't detect it or sound an alarm. Testing showed that
the dysrhythmia recognition software package hadn't
been installed. When it's installed properly, an indicator
is displayed on the patient's monitor screen.
A third case involved a
perinatal monitor. The staff didn't notice a visual
alarm that occurred when a fetal heart rate was outside
the defined parameters. In the investigation performed
later, biomedical engineers found that the equipment
was set up to provide only visual alarms and not audible
alarms. The report stated that audible alarms could
have prevented a serious outcome.
What went wrong?
In events like these, users aren't familiar with the
monitoring equipment or fail to recognize or confirm
the status of the alarms or dysrhythmia detection. Alarms
can very easily be disabled or silenced, either temporarily
or permanently. It's also easy to overlook onscreen
symbols that indicate that an important feature (such
as dysrhythmia detection or alarm volume) isn't engaged
or available.
A search of the FDA's Manufacturer
and User Facility Device Experience (MAUDE) database
yielded 566 alarm-related death reports from 2005 to
2008. Follow-up investigations often showed that users
weren't familiar with how the monitoring equipment worked
or hadn't checked the monitor's alarm status.
What precautions
can you take?
To avoid alarm-related adverse events, use these suggestions:
- Don't silence alarms
without first checking on the patient.
- Be sure to correctly
discharge patients from their monitors on their transfer
or discharge from the bed, unit, or hospital.
- Make sure that all
patient alarms are appropriately activated and not
suspended, that dysrhythmia detection functions are
available and appropriately activated, and that the
alarm volume is high enough to be heard outside the
patient's room. Perform these checks when assuming
care of patients from colleagues, after shift changes,
and after patients are transferred.
- Become familiar with
all monitor functions, especially dysrhythmia detection,
alarms, and icons on the screen, and the meanings
of various alarm sounds.
- Make sure that new
staff members, including travel and float nurses,
are adequately trained on the unit's monitors before
they care for monitored patients.
- Never rely solely on
pagers, mobile phones, and other secondary alarm enhancements
for alarm communication.
- Learn the hospital's
backup plan if monitors become dysfunctional and make
sure that the plan is readily accessible to staff.
It should also be in your hospital or unit's policies
and procedures.
- Immediately report
any device malfunctions or concerns to the biomedical
or clinical engineering team. Remove the device from
operation according to the hospital's policies and
procedures until it's been evaluated.
ECRI weighs in
The ECRI Institute has identified these alarm hazards
for clinicians:1
- Carefully evaluate
the device being considered for purchase and include
key personnel, such as clinical users, in the decision
process.
- Evaluate how the device
handles alarms. Is it configured in a way that's logical,
safe, and consistent with your facility's practice?
- Make sure that the
staff understands the purpose and significance of
each alarm.
- Make sure that alarms
are quickly and consistently conveyed to all required
staff, from monitor technicians to clinical staff
caring for monitored patients. Important considerations
include speaker volume, floor layout, and physical
distance of the device to the nearest staff member.
- Use monitors and alarms
as they're intended to help keep your patients safe.
Reference
1. ECRI. Top 10 health technology hazards. Health
Devices. 2008;37(11):343-350.
Resources
American College of Clinical Engineering. Clinical alarms
management and integration. http://www.acce-htf.org/clinical.asp.
Impact of Clinical Alarms on Patient Safety. Plymouth
Meeting, PA: American College of Clinical Engineering
Healthcare Technology Foundation, 2006. http://www.acce-htf.org/White%20Paper.pdf.
Source:
Nursing2009. September 2009.
|