Friday, April 12, 2013

Alarm Fatigue

According to a news article published by The Joint Commission, the constant beeping of alarms and the overabundance of information transmitted by medical devices are causing “alarm fatigue” and is putting patients at risk.

Over a four-year period, The Joint Commission sentinel event database reported 80 alarm-related deaths and the U.S. Food and Drug Administration database reported more than 560 alarm-related deaths.

Alarms in patient rooms are there to alert caregivers of potential problems, but if they are not properly managed, safety can be compromised. Warning noises tend to desensitize caregivers and can cause them to ignore alarms or even disable them. Sometimes there are too many medical devices with alarms or individual alarms can be difficult to hear.

The Joint Commission recommends that health care organizations take the following actions:

  • Ensure that there is a process for safe alarm management and response in areas identified by the organization as high risk.
  • Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and the limits appropriate for each care area.
  • Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions; include identification of situations when alarm signals are not clinically necessary.
  • Establish guidelines for tailoring alarm settings and limits for individual patients. The guidelines should address situations when limits can be modified to minimize alarm signals and the extent to which alarms can be modified to minimize alarm signals.
  • Inspect, check and maintain alarm-equipped medical devices to provide for accurate and appropriate alarm settings, proper operation, and detectability. Base the frequency of these activities on criteria such as manufacturers’ recommendations, risk levels and current experience.
Since this is a growing issue, The Joint Commission is also considering creating this as a National Patient Safety Goal so health care organizations can be more educated on the matter.  

Wednesday, April 10, 2013

Product Recall

Photo credit,
Photo Credit:

Approximately 9,000 Imaginarium Activity Walkers have been recalled from Toys R Us due to a choking hazard.

Currently, the company has received five reports of the front wheels detaching, which can pose a risk to children. The recalled product has a model number of 5F5E972 which is located on the bottom.

No injuries have been reported as of right now. Consumers can return the product to an Toys R Us store and get a full refund or store credit.

Friday, April 5, 2013

Hand Hygiene

Taken from Becker's Hospital Review:
Here, Gina Pugliese, RN, MS, vice president of the Premier healthcare alliance's Safety Institute, explains why hand hygiene should be a patient safety priority, and how healthcare organizations can succeed in improving hand hygiene compliance.
Question: Patient safety includes a wide range of issues, from patient falls to medication errors and hospital-acquired infections. What one patient safety issue do you think should be a priority in hospitals and health systems?    

Gina Pugliese: Hand hygiene is one of the most important patient safety issues today. And, it is the single most important factor in preventing the spread of pathogens and healthcare-associated infections. Low compliance with this basic patient safety measure may represent a lack of compliance with other patient safety practices. Despite attention to public reporting, reduced reimbursement initiatives for certain healthcare-associated infections, and international attention by public health, professional and accreditation organizations, it has been a challenge to reach and sustain hand hygiene rates over 80 percent in many healthcare facilities.

Q: What are the biggest barriers to improving hand hygiene?
GP: All the systems must be in place to support hand hygiene and make it easy for staff to adhere. This includes staff education on the importance and indications for hand hygiene; convenient location of sinks and dispensers; all dispensers in working order and filled with hand hygiene products that are not drying or irritating to the skin and [that are] acceptable to staff. 

Q: What are the biggest opportunities for improving hand hygiene?

GP: The organizational culture must have the right balance between no-blame and individual accountability for noncompliance with safety practices. In most high reliability industries, such as the airline industry, once a reasonable safety rule has been scrutinized for strong evidence to support it, found to have no unintended consequences and then becomes implemented, a worker who fails to follow the rule becomes accountable for failure to comply. There needs to be a consistent, fair and transparent method to monitor adherence to recommended practices for hand hygiene and the behaviors for which staff will be held accountable.  

Some hospitals have been very successful with incentives and rewards to improve hand hygiene compliance. Any penalties for failure to adhere to patient safety standards must be understood by all staff and applied fairly and proportional to the infraction. Penalties are not intended for a busy or distracted caregiver that may forget to wash their hands, but rather habitual and intentional failure to perform hand hygiene despite education, repeat counseling and corrections of any identified systems issues. Penalties for failure to adhere to appropriate hand hygiene vary, and have included the linking of compliance to merit increases for salaried staff and temporary loss of clinical privileges for physicians.

Wednesday, April 3, 2013

Patient Safety App

After a mother died from a preventable medical error, her family took action into their own hands.

After getting knee surgery, Louise Batz was given two narcotics and a sedative; once the combination of medicine was in her system, she stopped breathing and suffered irreversible brain damage. Eleven days later, she was taken off life support and died. Because Batz displayed signs of sleep apnea, she should not have been given that combination of drugs. Her death was completely preventable.

After Batz’s death, her family co-founded the Louise H. Batz Patient Safety Foundation so other families wouldn’t have to endure the same traumatic experience of losing a loved one. With the help from a medical advisory board, they created The Batz Guide for Bedside Advocacy.

This guide is now an iPad app that allows patients and their loved ones a way to monitor medical care to improve safety. They can log medications, look up medical terms, track vital signs and more. The app can be downloaded for $2.99. The goal of the app is to facilitate communication by helping patients and families know which questions to ask in order to help prevent errors.