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Ambre Ellison

on 29 April 2015

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Thank You!
What is alarm fatigue?
the desensitization that results from the inundation of the overwhelming amount of alarms that sound in the healthcare setting every day
studies have shown that anywhere from 72% to 99% of alarms are false
this causes staff to silence alarms, turn alarms off, widen parameters to unsafe levels or ignore alarms altogether (Funk, Clark, Bauld, Ott, & Coss, 2014)
Why so important?
Hospitals across the nation volunteered information to joint commission from '09 to '12. The data revealed 98 alarm related occurences--> 80 DEATHS, 5 increased LOS, and 13 with lasting loss of function. Thought to be only about 10% of actual cases (Mitka, 2013)
a patient undergoing abdominal surgery, alarms turned off for an intraoperative radiograph and never turned back on. The patient developed respiratory distress which went unnoticed. The patient died 11 days later.
a 17 yo had respiratory depression post tonsillectomy and the monitors were muted which caused her depression to be missed which resulted in death (Sendelbach, S., Funk, M., & Tracy, M., 2013)
at UMass memorial, a heart alarm went off for approx 75 minutes without response due to low battery. When pt went into cardiac arrest, no sound made (due to dead battery) and therefore no response
a 60 yo male had an unanswered alarm of an hour showing rapid HR and breathing issues. The man died. (Kowalczyk, 2011)
Joint Commission answers
the issue of alarm fatigue is now a patient safety goal and the goal sts to "improve the safety of clinical alarm systems."
the goal is two pronged
hospitals were to realize alarm fatigue as a priority by July 2014
hospitals were to prioritize alarms by obtaining data from staff, assessing the risk to patients if alarms not answered or if failed, if these certain alarms actually help or only add to cacophony of sound and then develop further guidelines
2nd part is to be implemented by Jan 2016
P&P are to be developed that address items such as who has the authority to change parameters, turn alarms off, when alarms can be disabled, etc
education regarding the purpose and correct operation of the alarms which staff members are responsible ( National Patient Safety Goals (NPSG), 2013)
Alarm Fatigue
What Can Nurse Educators do?
discuss the five areas that need to be addressed
decreasing false alarms
reducing alarms that require no action
discontinue monitoring when not appropriate
create/purchase better alarms
improving alarm care
education regarding alarm fatigue itself
discuss issues such as how is the nursing community addressing alarm fatigue at the bedside, what are hospitals doing to decrease the issue and what new strategies can be implemented
decreasing false alarms (HOW?)
change parameters as needed
stop over monitoring (Lesson learned, 2012)
Why prezi?
visually appealling
import many things (PDF's, PP's, YouTube video, music)
interactive (group work can be done, up to 10 people can work in real time)
promotes critical thinking with concept map approach
no software or downloading needed, can be all cloud based
simplistic so can focus on idea
appeals to the visual, kinesthetic and auditory learner
(Prezi in education, 2010)(Prezi 2014)(Billings & Halstead, 2012)(White, n.d.)
Let's change this
Billings, D. M., & Halstead, J. A. (2012). Teaching in nursing:A guide for faculty (4th ed.). St. Louis, MO: Elsevier Saunders.
Funk, M., Clark, J. T., Bauld, T., Ott, J., & Coss, P. (2014). Attitudes and practices related to clinical alarms [Entire issue]. American Jounal of Critical Care, 23(3). http://dx.doi.org/10.4037/ajcc2014315
Kowalczyk, L. (2011, December 29). State reports detail 11 patient deaths linked to alarm fatigue in Massachusetts - The Boston Globe. Retrieved April 25, 2015, from http://www.bostonglobe.com/metro/2011/12/29/state-reports-detail-patient-deaths-linked-alarm-fatigue-massachusetts/C8y3itRvd4WiGnR40sVHxN/story.html
Mitka, M. (2013, June 12). Joint commission warns of alarm fatigue [article]. The Journal of the American Medical Association, 309(22), 2315-6. http://dx.doi.org/10.1001/jama.2013.6032
Monitor alarm fatigue: Lessons learned [pdf]. (2012, June 25). Retrieved from http://www.npsf.org/wp-content/uploads/2012/06/PLS_12-6_CV_MF_Alarm_Fatigue.pdf
National patient safety goals effective January 1, 2014 [PDF]. (2013). Retrieved from http://www.jointcommission.org/assets/1/6/CAH_NPSG_Chapter_2014.pdf
Prezi . (2014). http://prezi.com/prezi-for-education/
Schwartz, A. (2013). Acute and transitional care: Battling alarm fatigue. Retrieved from http://scienceofcaring.ucsf.edu/acute-and-transitional-care/battling-alarm-fatigue
Sendelbach, S., Funk, M., & Tracy, M. (2013). Alarm Fatigue: A Patient Safety Concern. AACN Advanced Critical Care, 24(4), 378-386. Retrieved April 25, 2015, from http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=1617134
Using prezi in education. (2010). Retrieved from http://www.bbcactive.com/BBCActiveIdeasandResources/UsingPreziInEducation.aspx
White, N. (n.d.). Prezi v powerpoint: Finding the right tool for the job (Doctoral dissertation, State University of New York Institute of Technology). Retrieved from https://docushare.sunyit.edu/dsweb/Get/Document-196824/White_ThesisProject2.pdf
to this
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