Errors in Using Medical Alarms

 

An FDA article in the journal Nursing2009 describes problems that can arise with the use alarms on patient monitoring equipment. From 2005 through 2008, FDA received 566 reports of patient deaths related to the alarms on monitoring devices. Part of the problem is that alarms can very easily be disabled or silenced. Also, it is easy to overlook onscreen symbols indicating that an important alarm feature is not turned on or available. In many of the FDA reports, users were not familiar with how the monitoring equipment worked, or hadn’t checked the monitor’s alarm status.

In one case, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor sounding or displaying an alarm. It turned out that although the monitor detected the problem, its dysrhythmia processing had been turned off.

And in another case, an infant died when staff members did not notice a visual alarm on the screen of the perinatal monitor, warning that the child’s heart rate was outside the defined parameters. The equipment had not been set up to provide audible alarms.

Here are some of the things FDA recommends to avoid alarm-related patient injuries and fatalities.

• Do not silence alarms without first checking on the patient.

• 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 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 patients.

FDA Patient Safety News: January 2011