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Clinical alarms: complexity and common sense.

JoAnne Phillips¹

¹The Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA. joanne.phillips@uphs.upenn.edu

Critical Care Nursing Clinics of North America

|May 27, 2006

Summary

Mechanical ventilator alarms are critical for patient safety. A review found many deaths and injuries were linked to alarm issues, prompting new safety goals.

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Area of Science:

Biomedical Engineering
Patient Safety
Healthcare Quality Improvement

Background:

A 2002 review by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) examined 23 patient safety events related to mechanical ventilation.
Nineteen of these events resulted in death, and 4 led to coma, with 65% attributed to issues with ventilator alarms.

Purpose of the Study:

To analyze the findings of the JCAHO review concerning mechanical ventilation alarm safety.
To highlight the critical need for improved alarm management in healthcare settings.
To introduce the integration of alarm safety into the National Patient Safety Goals.

Main Methods:

Review of reported sentinel events related to mechanical ventilation.
Analysis of contributing factors to patient harm, specifically focusing on alarm system failures.
Examination of JCAHO's response and subsequent inclusion of alarm safety in patient safety initiatives.

Main Results:

A significant percentage of severe patient outcomes (death or coma) were associated with mechanical ventilator alarm malfunctions or failures in response.
Common alarm-related issues included delayed or absent responses, incorrect settings, lack of alarms for specific disconnections, and inaudible alarms.
The findings underscored the inadequacy of existing alarm safety protocols.

Conclusions:

Mechanical ventilator alarm safety is a critical component of patient care and requires robust programmatic solutions.
The identified issues necessitate a comprehensive approach to alarm management, encompassing technical and human factors.
The JCAHO's actions reflect a growing recognition of alarm safety as a priority for preventing adverse events in healthcare.

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