Monitor alarm 'fatigue' on the rise
September 14, 2010
by Heather Mayer, DOTmed News Reporter
This report originally appeared in the July 2010 issue of DOTmed Business News
As hospitals become more technologically advanced, technology-related hazards are on the rise. One hazard in particular has made headlines this year: monitor alarms. As monitors don more bells and whistles to keep tabs on patients' progress, and ironically, their safety, hospital personnel tends to tune out the incessant beeping and buzzing.
The Joint Commission found in its 2004 research that "occasionally, nurses put gauze over [monitor] speakers that are too loud and disturb patients who are sleeping," says George Mills, senior engineer of Joint Commission standards division. "Some older equipment is silenced until you turn it on. There's a problem where [staff] disable the alarm, and patient care is possibly put at risk, and it's just not good practice."
In January, a Massachusetts General Hospital patient died after his monitor alarm was left off by a hospital staff member. This event brought in the Joint Commission to investigate the situation. Mills speculates that after adverse incidents relating to monitor alarms, education about the importance of alarms goes up, but as time goes on and those staff members leave and new ones come in, people revert back to their old habits of turning alarms off or lowering their volume.
Monitor alarms consistently make the top 10 technology hazards list developed by the ECRI Institute, an organization that conducts research to investigate the best approaches to improve patient care from a patient safety perspective. The 2010 list has monitor alarms as the second-most hazardous device to patients.
"There are so many different types of devices and products that have alarms built into them that there are lots of opportunities for failures to occur," says Jim Keller, ECRI's vice president of health technology evaluation and safety. "And they happen. [We] routinely see death associated with alarm problems."
The hazard with monitor alarms is nothing new, says Carol Davis-Smith, who sits on the Association of Medical Instrumentation's technology management council. Even when the issue seems resolved through education and inspection, it crops up again, she says.
But the technology of monitor alarms is moving forward. For example, one idea is to prohibit alarms from being turned off or lowered at the central station where alarms are heard. Or, the alarm can be silenced, but will turn back on after a brief period of time - similar to how an alarm clock snooze button works.
"I think manufacturers recognize the importance [of effective alarms] as much as clinicians do," says Davis-Smith.
As the health care industry gets more technologically advanced, Keller says the technological hazards increase.
"The number of medical device-related hazards and alerts has gone up pretty significantly in the last 10 years," he says.
In 2000 there were about 250 medical device alerts; last year there were more than 2,000.
"Technology has become more and more complex," Keller explains. "With more features, there are more things that can go wrong."
On the other hand, medical technology has gotten a lot better, which has significantly improved patient care, creating a bit of a catch-22.
"We can't ignore the fact that with these new features, come new hazards," he reiterates. "Hospitals need to include safety management of technology as part of their operations."
As technology, especially monitor alarms, moves into the house for at-home patient use, there is a growing concern for patient safety because of the lack of trained support in the home. The technology, whether it is ventilators, oxygen machines, infusion pumps or monitoring devices, is left with the patient with little technical support.
"It's a problem waiting to happen," says Keller.
What needs to happen to avoid adverse patient safety events, experts say, is to offer training for handling medical technology, in addition to budgeting for technology safety.
"This isn't done as routinely as you would think," says Keller. "If you don't [budget] there's a good chance it won't happen."
As hospitals become more technologically advanced, technology-related hazards are on the rise. One hazard in particular has made headlines this year: monitor alarms. As monitors don more bells and whistles to keep tabs on patients' progress, and ironically, their safety, hospital personnel tends to tune out the incessant beeping and buzzing.
The Joint Commission found in its 2004 research that "occasionally, nurses put gauze over [monitor] speakers that are too loud and disturb patients who are sleeping," says George Mills, senior engineer of Joint Commission standards division. "Some older equipment is silenced until you turn it on. There's a problem where [staff] disable the alarm, and patient care is possibly put at risk, and it's just not good practice."
In January, a Massachusetts General Hospital patient died after his monitor alarm was left off by a hospital staff member. This event brought in the Joint Commission to investigate the situation. Mills speculates that after adverse incidents relating to monitor alarms, education about the importance of alarms goes up, but as time goes on and those staff members leave and new ones come in, people revert back to their old habits of turning alarms off or lowering their volume.
Monitor alarms consistently make the top 10 technology hazards list developed by the ECRI Institute, an organization that conducts research to investigate the best approaches to improve patient care from a patient safety perspective. The 2010 list has monitor alarms as the second-most hazardous device to patients.
"There are so many different types of devices and products that have alarms built into them that there are lots of opportunities for failures to occur," says Jim Keller, ECRI's vice president of health technology evaluation and safety. "And they happen. [We] routinely see death associated with alarm problems."
The hazard with monitor alarms is nothing new, says Carol Davis-Smith, who sits on the Association of Medical Instrumentation's technology management council. Even when the issue seems resolved through education and inspection, it crops up again, she says.
But the technology of monitor alarms is moving forward. For example, one idea is to prohibit alarms from being turned off or lowered at the central station where alarms are heard. Or, the alarm can be silenced, but will turn back on after a brief period of time - similar to how an alarm clock snooze button works.
"I think manufacturers recognize the importance [of effective alarms] as much as clinicians do," says Davis-Smith.
As the health care industry gets more technologically advanced, Keller says the technological hazards increase.
"The number of medical device-related hazards and alerts has gone up pretty significantly in the last 10 years," he says.
In 2000 there were about 250 medical device alerts; last year there were more than 2,000.
"Technology has become more and more complex," Keller explains. "With more features, there are more things that can go wrong."
On the other hand, medical technology has gotten a lot better, which has significantly improved patient care, creating a bit of a catch-22.
"We can't ignore the fact that with these new features, come new hazards," he reiterates. "Hospitals need to include safety management of technology as part of their operations."
As technology, especially monitor alarms, moves into the house for at-home patient use, there is a growing concern for patient safety because of the lack of trained support in the home. The technology, whether it is ventilators, oxygen machines, infusion pumps or monitoring devices, is left with the patient with little technical support.
"It's a problem waiting to happen," says Keller.
What needs to happen to avoid adverse patient safety events, experts say, is to offer training for handling medical technology, in addition to budgeting for technology safety.
"This isn't done as routinely as you would think," says Keller. "If you don't [budget] there's a good chance it won't happen."