Using PDSA to Reduce Alarm Fatigue

Problem: On our larger  critical care units, the occurrence of physiologic alarms can sound more than 100,000 times in any given month. We aimed to study the effect of modifying nonactionable alarms to reduce occurrences of alarms and improve staff perceptions of alarm fatigue.

Measurement: Used PDSA to apply structure and tests of change Reviewed physiologic monitoring data to identify alarms which do not require clinician intervention. Collected staff responses to an electronic survey emailed to them.

Analysis: We analyzed physiologic alarm occurrences before and after implementation, determine the percentage of change We used an electronic survey tool to collate responses and generate results We queried our patient safety event reporting system for alarm related events

Implementation: Sixty-eight alarms reviewed, 56 “MEDIUM” and 8 “LOW” level alarms underwent modifications.Decreased the central monitoring station decibel level from 70% to 60%. Formalized alarm responsibilities, definitions, and response times in hospital policy. Educated staff and safety coaches to reinforce key messages about alarm safety.

Results/Discussion: In our first measurement after alarm modifications were made, for both units combined, the results were an ALARMING reduction in alarm occurrences by 61%. Staff responses to the alarm fatigue survey showed a 14% improvement.

Senior Clinical Quality Manager
Senior Clinical Quality Manager - MedStar Washington Hospital Center

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