|
|
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. |