Clinical alarms: complexity and common sense.
In 2002, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) reviewed 23 reports of death or injury that were related to mechanical ventilation. Nineteen of those events resulted in death, and 4 resulted in coma; 65% were related to alarms. The issues included delayed or no response to the alarm; the alarm was off or set incorrectly; no alarms for certain types of ventilator disconnections; or the alarm was not audible in all areas of patient care. This review prompted JCAHO to include alarm safety in the National Patient Safety Goals for 2003. This article examines the components of an alarm safety program, from the complex to the common sense.
Phillips
JoAnne
J
The Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA. joanne.phillips@uphs.upenn.edu
D015984:Causality; D002983:Clinical Competence; D003422:Critical Care / Q000458:organization & administration*; D004868:Equipment Failure; D004869:Equipment Safety; D006804:Ergonomics; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D008991:Monitoring, Physiologic / Q000295:instrumentation; D010564:Personnel, Hospital / Q000193:education / Q000523:psychology / Q000600:supply & distribution; D012121:Respiration, Artificial / Q000009:adverse effects / Q000401:mortality; D018570:Risk Assessment / Q000458:organization & administration*; D017751:Safety Management / Q000458:organization & administration*; D013597:Systems Analysis; D013997:Time Factors; D014481:United States; D014486:United States Food and Drug Administration; D012122:Ventilators, Mechanical / Q000009:adverse effects; D016526:Workload