The ECRI Institute identified alarm hazards due to inadequate alarm configuration policies and practices as the no. 1 health technology hazard for 2015.1 The factors that led to inclusion on the list include severity (likelihood of serious injury), frequency, breadth, insidiousness, profile (likelihood of publicity), and preventability. Clinical alarms are obviously designed to support patient safety. However, the number and variety of alarms within a clinical area tend to create sensory overload for caregivers who tune out the constant drone of beeps and bells. As described in a previous column about alert fatigue,2 a philosophy of alarm priorities and working with staff to create mental models of alarms as mission critical safety nets was important to enhance safety.

While alarm fatigue can lead to desensitization of the need to respond, the manner in which alarms are configured requires more attention. The clinical nurse specialist (CNS) can be integral in bringing forward the evidence to set alarms at appropriate levels so that caregivers are alerted when appropriate and not for insignificant situations. Fatigue is not the only consequence of alarms. Observational studies have cited that interruptions (often caused by alarms) increase the risk and severity of medication administration errors.3

The Joint Commission identified reducing harm associated with clinical alarm systems as a hospital patient safety goal for 2015.4 The Joint Commission has provided greater specificity to guide hospitals in improving the safety of alarm systems, with 4 key performance elements. First, leaders must establish alarm safety as a hospital priority. Second, prioritization of the alarms must be based on

* input from medical staff and clinic departments,

* risk to patients if the alarm signal is not attended to or if it malfunctions,

* whether specific alarm signals are needed,

* potential for patient harm based on internal incident history,

* published best practices and guidelines.

Third, policies and procedures for alarm management must address

* clinically appropriate settings for alarm signals;

* when alarm signals can be disabled;

* when alarm parameters can be changed;

* who in the organization has the authority to

[white circle] set alarm parameters,

[white circle] change alarm parameters, and

[white circle] set alarm parameters to "off";

* monitoring and responding to alarm signals; and

* checking individual alarm signals for accurate settings, proper operation, and detectability.

Finally, staff and providers must be educated about the alarms for which they are responsible.

The implementation of these performance elements involves all three spheres of influence for the CNS: organization/system, nurses and nursing practice, and patient/client.5 In the organization/system sphere, 1 of the CNS competencies is to plan for achieving system-wide outcomes. The CNS has a role in working with leadership to foster a culture of safety within the institution and make alarm system safety a priority. Specifically, it is essential that the CNS be involved in deciding who in the organization has the authority to set, change, or turn off alarm parameters. One outcome of CNS practice in the sphere of nurses and nursing practice is to develop, implement, and evaluate educational programs that link evidence-based practice with clinical outcomes. The CNS should be involved in the development of educational programs that facilitate alarm safety as well as the monitoring of alarms for specific technologies. Furthermore, the CNS should draw conclusions about the evidence base for alarm policies and recommend nursing practices that should change to improve safety.

In the patient/client sphere of influence, the CNS prevents unintended consequences and errors. It is essential that the CNS be involved in bringing forth the evidence and best practices to appropriately set alarm parameters to facilitate alarms when a patient's condition requires attention by staff. It is also important for the CNS to be part of the interprofessional team that evaluates implementation of alarm safety policies to monitor progress toward outcomes.

A report from Abbott Northwestern Hospital described an alarm safety project in which the intensive care unit changed the default settings of pulse-rate alarms and found that alarms dropped 76% in 6 months, with no negative consequences.6 Completing a critical assessment of alarms, current settings, and frequency of false alarms is an important intervention by the CNS to help determine best practice for alarm limits specific to the patient and patient population. Several organizations provide tool kits to assist with the assessment of alarm accuracy to develop more patient- and practice-specific alarm parameters.7,8

Interestingly, there is an emerging technological solution to deal with the numerous interruptions and alarms. A type of software known as "middleware" is being used to reduce alarms. Middleware is software that brings 2 different information technology components together.9 One such application combines alarm notifications with a communication system so that all notifications are received on a single device, typically a smart phone.10 These systems provide a single, prioritized point of notification for the nurse. When combined with appropriate policies for alarm settings, they may streamline communication through the use of a single device, make the communication more useful by prioritizing notifications, and decrease interruptions caused by numerous alarms.

The CNS has an opportunity to understand the role of technology in creating a safety culture focused on more appropriate clinical alarms. This includes not only an awareness of current systems, but also having an eye to those that may be on the horizon.

References