Running head: MISSED ALARMS 1

Missed Alarms and Inappropriately Configured Notification Systems

Karen Huacasi

University of San Diego

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Missed Alarms and Inappropriately Configured Notification Systems

Missed alarms may result from inappropriately configured secondary notification devices

and systems (ECRI Institute, 2017). This topic was discussed in the ECRI Institute’s “Top 10

Health Technology Hazards for 2018”. The ECRI Institute’s report explores the safety

implications of various medical devices and systems. To combat alarm fatigue in many medical

institutions today, alarms are sent from a primary alarm notification system, such as a bedside

monitor, to a secondary alarm notification system, such as a clinician’s smart phone. The

problem with this process is that these alarms are often missed. Sample reported causes of

missed alarms include alarm delivery delays when a system is overloaded, alarm delivery

failures after an antivirus software is installed, and phone freezing when users switch between

software applications (ECRI Institute, 2017). These issues can be avoided if systems are more

carefully configured, systems are verified and validated during implementation, and if system

integrity is periodically assessed when in use (ECRI Institute, 2017).

It is important to examine this topic because missed critical alarms can lead to delays in

care which can result in negative patient outcomes, and ultimately death. For example, in one

case a venous pressure alarm in a person undergoing hemodialysis through a forearm

arteriovenous fistula was continuously ignored. At the fourth alarm, the nurse assessed the arm

and found severe edema from infiltration of the venous needle. Because of the infiltration,

treatment had to be stopped, patient’s hemoglobin dropped because the patient’s blood could not

be returned, and a temporary central venous catheter had to be placed to continue dialysis

(Horkan, 2014). In another scenario, patient death resulted from a delay in alarm response

(Sendelbach & Funk, 2013). Although the true frequency of alarm-related events is difficult to

measure, health care accreditation agencies and patient safety organizations recognize alarm
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safety hazards as an issue that needs to be resolved in the health care industry (Lukasewicz &

Mattox, 2015).

The purpose of this paper is to explore the different causes of missed alarms that result

from poorly configured secondary alert systems. This paper also seeks to define evidence-based

interventions that will help prevent and reduce the frequency of missed alarms and the negative

patient outcomes that often go along with them. Nurses are in the unique position to lead

improvements in alarm practice. The information in this paper is meant to equip nurses with the

information they need to bring about change.

Literature Review

Upon review of literature related to alarm management, it became clear that there is no

simple solution to reducing missed alarms from poorly configured secondary alert systems. The

urgency to reduce the harm associated with clinical alarm systems was clear throughout each

study. Four solutions were identified and further studied. Most of the studies reviewed offered

solutions that involve a multifaceted systems approach.

Voepel-Lewis et al., (2013) conducted a prospective observational study aimed to

investigate unit and hospital factors related to nurse response time to pulse oximetry alarms,

missed alarms, and the correlation between missed alarms and patient interventions and

outcomes. A three-tiered system was implemented to alert nurses that the patient’s oxygen

saturation had fallen below the pre-defined setting. First, the audible bedside alarm would sound.

If the nurse did not respond after 15 seconds, an alarm page was sent to the nurse. After three

minutes of no response, an urgent page was sent to the nurse and charge nurse. Researchers

found that, “one-quarter of desaturation events did not trigger transmission of a notification

page,” resulting in a missed event (Voepel-Lewis et al., 2013, p. 1356). Researchers discovered
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that missed events occurred more often when paging burden was greater, which suggested that

hospital-level system factors play a role in missed alarm events (Voepel-Lewis et al., 2013).

The article, “Monitor Alarm Fatigue An Integrative Review” summarizes research and

non-research evidence related to alarm fatigue, notification systems, and evidence-based practice

recommendations (Cvach, 2012). The author recommends the use of closed-loop communication

when using alarm notification systems. The evidence-based practice recommendations provided

include; smart alarms with multiple adjustable parameters and alarms that use short delays to

decrease false alarms (Cvach, 2012). This would help prevent the problem of system overload

addressed in the introduction. Another recommendation is that hospitals include an

interdisciplinary team in an alarm management committee. Response protocols should be

developed and ongoing training should be provided on alarming devices (Cvach, 2012).

According to Addis, Cadet, & Graham (2014), one of the most common themes identified

in alarm-related event reports was that alarms did not go off because of a mistake on the part of

the user or an issue with the equipment. The authors suggested the assembly of an

interdisciplinary team to lead a hospital alarm program initiative. The ECRI Institute proposes

four tenets of alarm safety that should be addressed prior to creating an alarm management

program (Addis, Cadet & Graham, 2014). First, the leadership team should model and establish a

culture the values safety, accountability, and education among the staff. The second tenet is

infrastructure. The architectural layout, staffing patterns, models of care, and strategies for alarm

coverage should be reviewed and revised to improve workflow. Third, “process steps for alarm

notification, verification, and response will need to be clarified and communicated” (Addis,

Cadet & Graham, 2014, p. 43). Finally, alarm technology must be assessed to ensure that devices

are being used as intended and used to their fullest capabilities. It is also important to ensure that
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the technology interface is connecting smoothly with other devices (Addis, Cadet & Graham,

2014).

The systematic review titled “Managing Alarm System for Quality and Safety In the

Hospital Setting” is a collection of literature, grey literature, interviews, and alarm-related

standards that analyzed alarm system management in various hospital settings (Bach, Berglund

& Turk, 2018). The review sought to identify an approach to improve alarm safety in the hospital

by using human, organizational, and technical factors (Bach, Berglund & Turk, 2018). The

review led researchers to create a five-step guide for implementing their solution to improve

alarm management in the hospital. Step one is the formation of a multidisciplinary team. Step

two involves creating a culture of alarm safety, reviewing alarm inventory and prioritization,

assessing and evaluating alarms, and implementing co-created alarm protocols and procedures.

Step three requires continuous staff training on alarm management and the appropriate

configuration of alarm settings. Step four emphasizes the importance of measuring the outcomes

of these efforts. Step five requires that the learning that took place in step three be shared within

and between organizations (Bach, Berglund & Turk, 2018).

The four solutions discussed above have the potential to decrease missed alarms due to

poorly configured notification systems. Each of these solutions includes a component that

decreases the amount of false or non-actionable alarms that are sent to health care professionals

throughout the hospital. The first solution centered on the secondary alarm notification process,

and how the set up helped avoid missed notifications. The second article discussed several

solutions that involved the setup of a notification device like in the first article, but also staff

education and the creation of an alarm committee. The last articles provided more systematic

solutions that involve hospital culture, IT infrastructure, alarm safety protocols, and education.
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The solutions presented in Voepel-Lewis et al. (2013) and Bach, Berglund, and Turk (2018) have

been selected for further study in this paper. This solution is a comprehensive approach that

addresses the need to improve various areas within the hospital system to reduce missed alarms

and improve patient safety and quality of care.

Solution Description

Two solutions from the literature review will be combined to form one comprehensive

solution. The main solution is to implement a three-tiered alarm notification system as described

in the study conducted by Voepel-Lewis et al. (2013). This notification system includes an

audible bedside alarm, activation of a call light, and nursing page via the hospital paging system.

If a patient’s oxygen saturation or heart rate exceeds pre-set limits for 8 seconds, a bedside alarm

will ring and a solid green light will activate outside the room. If the staff does not address the

alarm in 15 seconds, an alarm page is sent to the bedside nurse, the display and tone of the

console at the central nursing station will change, and the green light outside the patient’s room

will begin to flash. If three minutes and 15 seconds of continuous desaturation pass, an urgent

page is sent to the bedside nurse and the charge nurse. Also, the console tone at the central

nursing station will change to double rate and the light outside the patient’s room will flash green

and white (Voepel-Lewis et al., 2013).

The implementation of a solution can determine the extent of success of a solution. Bach,

Berglund and Turk’s (2018) five step implementation plan can help optimize this process. The

first step involves forming a multidisciplinary team that brings together senior leaders, frontline

staff, information technology staff, and manufacturers. Next, leaders will need to discuss alarm

safety culture and alarm prioritization with staff. They will also need to develop a protocol for

individualizing alarm parameters and indications for pausing or resetting alarms. The third step
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will involve staff education and implementation of the solution. The team will then assess

measurable outcomes to evaluate the reduction of missed alarms. Finally, the organization will

share its findings with other institutions so that they too may improve their alarm safety

programs (Bach, Berglund & Turk, 2018).

This proposed solution is the best solution to address missed alarms due to secondary

notification systems. Every tier of the three-tiered alarm notification system ensures that the

bedside nurse, charge nurse, and anyone near the patient’s room and the nursing station is aware

of the activated alarm. One cause of missed alarms is alarm delivery delays when a system is

overloaded. Including reconfiguration of alarm settings and individualization of alarm

parameters in the implementation process helps to reduce the number of times an alarm is set off,

thereby reducing system overload. Including information technologists and manufacturers in the

implementation process ensures that the system is verified and validated before use. Finally,

having a multidisciplinary team that periodically evaluates system integrity helps to reduce the

number of missed alarms.

This three-tiered alarm notification system, paired with the five-step guide to

implementing the solution, will help reduce missed alarms. Patients will benefit from receiving a

necessary intervention prompted by an alarm that may have otherwise been missed. Alarm

fatigue will be reduced when health care providers no longer waste valuable time addressing un-

actionable alarms. Instead, healthcare workers will be able to provide better care without the fear

of missing an important alarm. They will be able to rely on the help of the rest of their team with

the deployment of additional pages and flashing call lights. Finally, the health care organization

will benefit as whole. The investment of time and money will be worthwhile because of the

reduction of missed alarms and enhancement of safety and quality of care.

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Quality Measurement Plan

A three-tiered alarm notification system is the proposed solution to the problem of missed

alarms in the health care. A quality measurement plan was created to help evaluate whether the

solution makes a difference, is effective, and is safe. The two quality indicators that will be used

to evaluate effectiveness are number of missed alarms and timing of responses. Because the

original problem was that too many alarms were being missed due to inappropriately configured

secondary notification devices, it is appropriate to measure the number of missed alarms after

implementing the solution. With a reduction of missed alarms, care should be safer and timelier.

Therefore, measuring the length of time between the alarm and a response will also help evaluate

the effectiveness of the solution. Baseline data will be collected before the three-tiered

notification system is implemented to compare to post-implementation data.

The multidisciplinary team assembled in step one of the five-step guide to implementing

the solution will be responsible for monitoring the quality indicators. Specifically, the

information technology staff will collect data, the data analysists will analyze the data, the entire

team will discuss the results, and the leaders will present these findings on a monthly basis.

The alarm notification system discussed in the solution will have the capability to log all

clinical alarms. It will track the start, stop and length of the alarm, the parameters, and the actual

physiological data produced by each patient during the alarm. It will also log where each alarm

was routed to and whether or not an alarm was responded to at all. This data will be transferred

to an analytics tool so that the data can be sorted, trended, and visualized. The results will be

compared to the baseline data collected before implementation of the solution.

Quality indicators will be evaluated every month. Data logged in the clinical alarm

devices will be collected on a random shift (day or night), two times a week, for every patient
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being monitored on the unit. Progress will be presented to the project team and to the clinical

staff every month.

Conclusion

According to the ECRI Institute’s report, missed alarms are a health technology hazard that

may result from inappropriately configured secondary notification devices. This topic is

important because missed critical alarms can result in negative patient outcomes, and even death.

It is important to understand the different causes of missed alarms so that interventions can be

implemented to help prevent and reduce them.

Two solutions were combined to form one comprehensive solution. Significant elements of

the solution include: a multidisciplinary implementation team, a three-tiered alarm notification

system, and individualization of alarm parameters. This solution is expected to be effective

because it ensures that the bedside nurse, charge nurse, and anyone near the patient’s room and

the nursing station is aware of the activated alarm. Also, individualization of alarm parameters

will help reduce the number of alarms, thus reducing system overload. Before organization wide

implementation of this solution, it is recommended that a pilot study be performed. This way, the

team can work out specific details and tackle problems on a smaller scale. If positive outcomes

are observed, this solution should be implemented where the need is identified. Missed alarm

pose a real threat to patient safety. Future research should focus on identifying better solutions to

this problem so that patients can benefit from safer, better care.
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References

Addis, L. M., Cadet, V. N., & Graham, K. C. (2014). Sound the Alarm. Patient Safety & Quality

Healthcare,(May/June), 40-44. Retrieved from https://www.psqh.com/analysis/sound-

the-alarm/.

Alarm Interventions during Medical Telemetry Monitoring: A Failure Mode & Effects

Analysis (Publication). (2008). Retrieved November 6, 2018, from Pennsylvania Patient

Safety Authority website:

http://patientsafety.pa.gov/ADVISORIES/documents/2008sup1_home.pdf

Bach, T. A., Berglund, L., & Turk, E. (2018). Managing alarm systems for quality and safety in

the hospital setting. BMJ Open Quality, 7(3). doi:10.1136/bmjoq-2017-000202

Cvach, M. (2012). Monitor Alarm Fatigue: An Integrative Review. Biomedical Instrumentation

& Technology, 46(4), 268-277. doi:10.2345/0899-8205-46.4.268

ECRI Institute. (2017). Top Executive Brief: 10 Health Technology Hazards for 2018. 1-16.

Retrieved September 23, 2018, from

https://www.ecri.org/Resources/Whitepapers_and_reports/Haz_18.pdf

Horkan, A. M. (2014). Alarm Fatigue and Patient Safety. Nephrology Nursing Journal, 41(1),

83–85. Retrieved from

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Lukasewicz, C. L., & Andersson Mattox, E. (2015). Patient Safety. Understanding Clinical

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org.sandiego.idm.oclc.org/10.4037/ccn2015113
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Sendelbach, S., & Funk, M. (2013). Alarm Fatigue: A Patient Safety Concern. AACN Advanced

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Voepel-Lewis, T., Parker, M. L., Burke, C. N., Hemberg, J., Perlin, L., Kai, S., & Ramachandran,

S. K. (2013). Pulse oximetry desaturation alarms on a general postoperative adult unit: A

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