Alarms at Mass General /
Mass. incident highlights need for protocols check
After a recent CMS report ruled that nurses’ desensitization to monitor alarms played a role in the death of a cardiac patient, more hospitals are taking heed and examining the problem, known as alarm fatigue, in their own organizations.
The incident occurred on an early January morning at 907-bed Massachusetts General Hospital, Boston. The patient was one of 31 others on a surgical floor staffed by 10 nurses, according to the April 2 report. A review of cardiac monitor logs showed that during a 20minute period, the patient’s heart rate dropped rapidly and eventually stopped, and subsequent resuscitation efforts were unsuccessful.
Nurses did not report hearing repeated warning alarms, and the volume on the patient’s bedside crisis alarm, which alerts staff to an arrhythmia, was in the “off” setting, said Gregg Meyer, Massachusetts General’s senior vice president for quality and safety.
The event highlighted a number of significant problems, including the discovery that scrolled volume functions on bedside alarms had an off setting that could be applied easily and inadvertently—something that was not well-known among staff, Meyer said.
Despite the tragedy, Meyer said he was pleased the staff had followed proper protocol for a serious safety event. Nurses on the floor immediately completed a report and notified administrators, who then alerted the state’s public health department.
Officials from the CMS knew of the event already when they arrived at Massachusetts General in February for a random validation survey, and they were able to examine the incident in detail while at the hospital, said Roseanne Pawelec, spokeswoman for the CMS’ regional office.
“CMS did not uncover a rock during their survey,” Meyer said. “We had already shared this openly.”
Since the incident, the staff at Massachusetts General has disabled the off setting on more than 1,100 monitors, installed distributed speakers so volume settings on alarms do not have to be turned up so high, standardized alarm volumes, and instituted a review process for any changes to default settings. Additionally, the staff has created a training program that reviews monitor technology, and has formed a committee charged with creating best practices and standards for alarm use, said Jeanette Ives Erickson, senior vice president for patient care and chief nurse at the hospital.
“The team is reviewing standards to see which patients really need to be on monitors,” Meyer said. “We have immediately seen more discussion at the unit level, and we’ve discovered it’s a topic that needs to be part of shiftto-shift handoff conversations.”
Alarm fatigue is not unique to Massachusetts General. Several years ago, prompted by a fear that excessive alarms had desensitized nursing staff, 925-bed Johns Hopkins Hospital, Baltimore, began a quality improvement project, the results of which were published in the January issue of the American Journal of Critical Care.
The findings were eye-opening, said Maria Cvach, assistant director of nursing, clinical standards, and co-author of the article. The hospital’s medical progressive care unit had a staggering 500 alarms per patient per day—most of which were low-priority and required no intervention, but made for a very noisy environment, she said. Through the improvement program, the hospital was able to reduce that number to 200.
The key, said Cvach, is setting realistic, actionable alarm parameters based on your patient population. For instance, if a unit has a large number of respiratory patients with chronic lung disease, it’s not productive to set alarms on pulse oxygenation monitors based on normal lung-function values.
Cvach also advised creating some kind of backup system to provide a safeguard against errors. Some hospitals deliver an additional notification via pager, cell phone or marquee sign. Others have taken an extra step and added a monitor technician whose job is to serve as an extra pair of eyes and make sure lethal rhythms or deteriorating status do not go unnoticed.
The increasing focus on alarm fatigue is just one part of a larger trend of patient-safety awareness, said Andrea Kline, pediatric nurse practitioner at Riley Hospital for Children, part of 1,385-bed Clarian Health Partners, Indianapolis. Earlier this year, while working at 247-bed Children’s Memorial Hospital, Chicago, Kline developed a 24-question survey on alarm fatigue, sent it to 300 critical-care nurses at 681-bed Rush University Medical Center, Chicago, and presented results from the 94 responses she received at the Society of Critical Care Medicine’s annual Critical Care Congress in January.
The survey indicated that alarms were often not set appropriately for patients, and nurses often worried about unintentionally missing one, Kline said.
Despite receiving more attention in the past few months, alarm fatigue was on the Joint Commission’s radar in 2003 when it named it as one if its National Patient Safety Goals, said Paul Schyve, the organization’s senior vice president. It was deleted in 2005 because reports had improved significantly, he said, but that trend has changed and the numbers are creeping back up once again. A constant stream of alarms can easily lead to fatigue, Schyve said, drawing an analogy to the frequent alerts often present in computerized physician order-entry systems.
There were two parts to the initial 2003 patient-safety goal regarding alarm fatigue: regular maintenance and ensuring alarm volumes were set high enough. In 2004, there were nine reports of noncompliance from surveyors; that number has since climbed to more than 30.
At Massachusetts General, transparency and quick action has helped make the best out of a very unfortunate situation, Erickson said.
“We know this is a national issue and something that happens at other hospitals,” Meyer said. “It has galvanized us to look at our culture, make improvements in our processes, and do the right thing for our patients.”
Alarm fatigue can occur when nurses work in excessively noisy environments or face high numbers of low-priority alerts.