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2011 Why Clinical Alarms Are a ‘Top Ten’ Hazard
Why Clinical Alarms Are a ‘Top Ten’ Hazard:?How You Can Help Reduce the Risk
James P.?Keller,?Rich?Diefes,?Kelly?Graham,?Mark?Meyers, and?Kathy?Pelczarski
About the Authors
James P. Keller, MS, is vice president of health technology evaluation and safety at the ECRI Institute. Email:?jkeller@
Richard Diefes, MS, is director of operations with the health devices group at ECRI Institute. Email:?rdiefes@
Kelly Graham, RN, BSN, is a patient safety analyst and consultant with ECRI Institute. Email:?kgraham@
Mark Meyers, RN, BSN, MBA, NE-BC is senior associate with the applied solutions group of the ECRI Institute. Email:?mmeyers@
Kathryn M Pelczarski, BS is director of the applied solutions group at the ECRI Institute. Email:?kpelczarski@
Published Online: 2011-03-01
Take a look around your hospital for medical devices and systems with alarms. Youll find them on infusion pumps, physiologic monitors, ventilators, anesthesia machines, dialysis units, laparoscopic insufflators, and so on. Its amazing how much the healthcare system has grown to rely on medical device alarms. It would be hard to walk into almost any type of patient room or care area and not find an alarm-based device being used. In critical care areas, its typical to find a dozen or more such devices, just for one patient. And these devices are now starting to become interconnected and are sharing lots of critical information, including alarm data.
With such widespread use of alarm-based medical devices, youd think we would have a very effective safety net to warn about serious changes in patient conditions or performance-and safety-related problems with devices. Unfortunately, as many experts agree, there are serious problems with the design and use of device-based clinical alarms. Clinical alarms have been at or near the top of the ECRI Institutes list of “Top 10 Health Technology Hazards” since the annual list was first published in 2007. It remains near the top because alarm-related events are all too com
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