Is likely the result of compound errors.Signals underlying weaknesses in the system or process.More often, bad outcomes are "sentinel events." A sentinel event is a significant negative outcome that: When bad things happen in a complex system, the cause is rarely a single act, event, or slip-up. SEI assists jurisdictions to build capacity and conduct their own sentinel event reviews to transform bad events into opportunities to address systemic flaws, prevent their recurrence, and earn public trust, thereby increasing safety, lowering costs, and instilling a culture of disclosure.
It seeks to empower local jurisdictions to take an all-stakeholder, non-blaming, forward-looking approach to learning from errors, with the goal of mitigating future risk. ECRI Institute has stated that staff education regarding proper alarm settings and use is the “first and most important step in reducing alarm-related errors.” More information on this topic can be found in the resources below.The Sentinel Events Initiative (SEI) is a joint project of the Bureau of Justice Assistance (BJA) and the National Institute of Justice (NIJ). Food and Drug Administration has received 216 reports from manufacturers regarding alarm-related deaths between January 2005 and June 2010. Analysis of alarm problems reported to the Pennsylvania Patient Safety Authority since June 2004 also found that this issue was involved in 35 deaths, and the U.S. As noted in the Sentinel Event Alert, this issue has been reported on by many organizations, including ECRI Institute in the Top 10 Health Technology Hazards, where alarm problems have appeared on the list every year since 2010. HRC Recommends: The recent analysis by the Joint Commission confirms that alarm problems can have serious, sometimes devastating, consequences. Other strategies suggested by the agency include providing training on the organization’s process for safe alarm management and response to all members of the clinical care team, changing sensors based on manufacturers’ recommendations, assessing the acoustics of patient care areas, and establishing a cross-disciplinary task force that includes representation from clinicians, clinical engineering, information technology, and risk management to address alarm safety and the potential impact of alarm fatigue in all patient care areas. The Joint Commission makes several recommendations, including many from ECRI Institute, to help healthcare organizations to improve safety surrounding alarm-equipped medical devices, including ensuring that there is a process for safe alarm management and response in high-risk areas (as identified by the organization) preparing an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions and identifying the default alarm settings and the limits appropriate for each care area establishing guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, including identification of situations when alarm signals are not clinically necessary establishing guidelines for tailoring alarm settings and limits for individual patients and inspecting, checking, and maintaining alarm-equipped devices to provide for accurate and appropriate alarm settings, proper operation, and detectability. Major contributing factors in the reported events included an absent or inadequate alarm system, improper alarm settings, alarm signals that were not audible in all areas, and alarm settings that were inappropriately turned off. According to the alert, alarm-related events are recognized as underreported and occur in all healthcare settings however, 94 of the reported events occurred in hospitals, with the majority of those events occurring in telemetry, intensive care, general medicine, or emergency department areas. Of the 98 alarm-related events that were reported to the Joint Commission’s sentinel event database between January 2009 and June 2012, 80 resulted in death, 13 in permanent loss of function, and 5 in unexpected additional care or extended stay. The sheer number of medical device alarm signals on some hospital units can cause some clinicians to become overwhelmed by information or desensitized or immune to the sounds, a condition known as “alarm fatigue,” which can have serious consequences to patient safety, states an April 8, 2013, Joint Commission Sentinel Event Alert. Aging Services Risk Quality and Safety Guidance.ECRI Permissions Agreement – Clinical Practice Guidelines.
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