Date of Completion
Quing Zhu, Frank Painter
Field of Study
Master of Science
Modern hospitals are plagued by excessive alarms generated by patient monitoring technologies with very high sensitivity and low selectivity leading to high rates of false and clinically irrelevant alarms. Multiple studies have shown that these false and clinically irrelevant alarm rates can negatively impact patient care and lead to "alarm fatigue". Alarm hazards have been named the number one health technology hazard by ECRI Institute for 2012 and 2013. A review by the FDA revealed 566 alarm related deaths in a recent four year period.
At a large, teaching hospital in Massachusetts, a quantitative, database driven approach to alarm management was adopted in the acute care and medical/surgical environment with the intent to identify and implement technological, clinical, educational, and workflow practice changes to curtail excessive alarming. A database representing a subset of the total alarm burden from patient monitoring devices was analyzed. The measured subset revealed a combined total of 31.5 arrhythmia and pulse oximetry alarms per patient per day. Observations determined the database contained 35%-55% of the total alarm burden.
Two countermeasures were successfully deployed, two were deployed with inconclusive results and four were developed and not deployed. The result of this ongoing effort was a reduction in the number and duration of clinically irrelevant, non-actionable alarms generated and a gradual shift in the culture surrounding monitoring alarms. The work conducted will serve as a roadmap for future process improvement work with patient monitoring systems.
Peterson, Jeffrey Thomas, "An Investigation into the Efficacy of Alarm Fatigue Reduction Strategies" (2013). Master's Theses. 432.
Dr John Enderle