Running head: MISSED ALARMS 1

Process Map

Solution Process Map: Implementing a Three-Tiered Notification System to

Reduce Missed Alarms

Develop
Begin project Form Evaluate Share findings
protocols for Implementation
to reduce multidisciplinary reduction of with other End project
alarm of solution
missed alarms team missed alarms institutions
parameters

1 2 3 4 5 6 7

1. Alarm page 1. Urgent page

sent to sent to
bedside nurse bedside and
2. Flashing charge nurse
Nurse sets Patient s Yes 1. Bedside Vital signs Yes
Vital signs Yes green light 2. Flashing
Three-tiered individualized vital signs alarm rings exceed pre- green and
exceed pre- outside
notification parameters exceed pre- 2. Solid green set limit for white light Finish
set limit for patient room
system on bedside set limits for light outside 3 min and outside
15 seconds 3. Display and
alarm 8 seconds patient room 15 sec patient room
tone of
nursing station 3. Display and
No No No tone of nurse
console
changes station console
changes to
double rate

Alarm
deactivated

Process step Potential Failure Potential Failure Potential Failure

Point #1 Point #2 Point #3
1. Nurse sets Alarm limits not Insufficient monitor Patient identified
individualized individualized skills: For ex: 82% incorrectly.
parameters on according to patient’s set as lower limit for
bedside alarm condition. oxygen saturation
instead of 92%.
2. Patient’s vital signs Incorrect vital signs Staff disconnects Bedside alarm
exceed the preset displayed on bedside patient from monitor disconnected from
limit for 8 seconds monitor. to move patient out of power source, thus no
bed but forgets to alarm.
reconnect patient
upon return to bed.
3. Bedside alarm Alarm not heard. Staff does not detect Bedside nurse is not
rings and solid green alarm due to alarm available to attend to
light activates outside fatigue. For example, alarm.
patient room a nurse nearby might
see that the light is
MISSED ALARMS 2

simply solid green

and decide to wait
until it starts to flash.
4. Vital signs exceed Incorrect vital signs Patient is Bedside alarm
pre-set limit for 15 displayed on bedside disconnected by a disconnected from
seconds monitor. staff member to move power source, thus no
out of bed, but not alarm.
reconnected upon
return to bed.
5. Alarm page sent to Bedside nurse is not Staff is too far from Delay in intervention.
bedside nurse, carrying pager the patient room to
flashing green light hear bedside alarm or
outside patient room, see flashing green
display and tone of light outside patient
nursing station room
console changes
6. Vital signs exceed Incorrect vital signs Patient is Bedside alarm
pre-set limit for 3 displayed on bedside disconnected by a disconnected from
minutes and 15 monitor. staff member to move power source, thus no
seconds out of bed, but not alarm.
reconnected upon
return to bed.
7. Urgent page sent to Both bedside and Staff are too far from Delay in intervention.
bedside and charge charge nurse forget to the patient room to
nurse, flashing green carry pager hear bedside alarm,
and white light see flashing green
outside patient room, light outside patient
display and tone of room, hear nurse
nurse station console station console tone
changes to double change to double rate
rate
8. Alarm deactivated Equipment failure: Equipment failure: Equipment failure:
alarm page not sent to alarm does not alarm does not
bedside or charge activate light outside activate nurse station
nurse patient room console tone change
MISSED ALARMS 3

Failure Mode Effect Analysis

1 Process Step Nurse sets individualized parameters on bedside alarm

2 Potential Alarm limits not Insufficient monitor Patient identified
Failure individualized skills: For ex: 82% set incorrectly.
Mode according to patient’s as lower limit for
condition. oxygen saturation
instead of 92%.
3 Potential Multidisciplinary team Nurse is in a hurry. Nurse mistakes one
Cause(s) was not involved in Inadequate training on patient’s
individualizing how to set up monitor individualized
parameters. Alarm parameters. parameters for
change limits were not another. Patient
communicated at identifiers not
handoff. checked.
4 Severity Major Major Major
Process Step #1

5 Probability Frequent Frequent Frequent

6 Hazard 12 12 12
Score
7 Action Control Control Control
(Eliminate,
Control, or
Accept)
8 Description Establish protocol for Provide education on Standardize using two
of Action adjusting alarm how to set up monitor patient identifiers.
parameters involving parameters. Establish Assign separate nurse
multidisciplinary team protocol for nurses to to patient’s with
per patient condition. double check alarm similar names. Provide
Include alarm parameters at handoff. education.
parameter changes in Encourage nurses to
nursing handoff slow down when
communication. setting parameters.
Establish default limits
based on patient
population in unit .
MISSED ALARMS 4

1 Process Step Patient’s vital signs exceed pre-set limits for 8 seconds
2 Potential Incorrect vital signs Staff disconnects Bedside alarm
Failure displayed on bedside patient from monitor to disconnected from
Mode monitor. move patient out of bed power source, thus no
but forgets to reconnect alarm.
patient upon return to
bed.
3 Potential Improperly placed or Patient needs to go to Accidental
Cause(s) disconnected sensors the restroom, patient disconnection. Patient
due to sweat. needs to be transported purposefully
for a procedure. disconnects.
4 Severity Major Major Major
Process Step #2

5 Probability Frequent Frequent Frequent

6 Hazard 12 12 12
Score
7 Action Control Control Control
(Eliminate,
Control, or
Accept)
8 Description Ensure proper skin Develop checklist for Establish protocol for
of Action preparation. Establish hand off between staff. periodic sensor
protocol for periodic Establish protocol for inspection and
sensor inspection and periodic sensor replacement. Place
replacement. Trial inspection and bedside alarm in a spot
different sensors that replacement. Establish that is not easily
work better. protocol for placing accidentally
patient back on disconnected from
continuous monitoring. power source. Place
power cord in a spot
out of reach of patient.

1 Process Step 1. Bedside alarm rings

2. Solid green light outside patient room
Process Step #3

2 Potential Alarm not heard. Staff does not detect Bedside nurse is not
Failure alarm due to alarm available to attend to
Mode fatigue. For example, a alarm.
nurse nearby might see
that the light is simply
solid green and decide
to wait until it starts to
flash.
MISSED ALARMS 5

3 Potential Staff are too far from Diminished sensitivity Bedside nurse is doing
Cause(s) the patient room to to low-priority alarms. other tasks. Bedside
hear bedside alarm or Alarm parameters not nurse is on break.
see solid green light individualized to
outside patient room. patient. Alarm
Alarm turned down or parameter default too
off. narrow.
4 Severity Major Major Moderate
5 Probability Frequent Occasional Occasional
6 Hazard 12 9 6
Score
7 Action Control Control Control
(Eliminate,
Control, or
Accept)
8 Description Place displays in Reduce nuisance Establish protocol for
of Action strategic locations. alarms. Adhere to available staff to cover
Require that alarm proper patient skin alarm response.
volume is always set prep. Establish Ensure adequate
at adequate level. minimum criteria for amount of staff to
Configure system to patients to be placed on provide this coverage.
prevent alarm volume bed alarm. Nurture a culture that
from being turned highly values
down too low or off. teamwork

1 Process Step Vital signs exceed pre-set limit for 15 seconds

2 Potential Incorrect vital signs Patient is disconnected Bedside alarm
Failure displayed on bedside by a staff member to disconnected from
Mode monitor. move out of bed, but power source, thus no
not reconnected upon alarm.
return to bed.
3 Potential Improperly placed or Patient needs to go to Accidental
Process Step #4

Cause(s) disconnected sensors the restroom, patient disconnection. Patient

due to sweat. needs to be transported purposefully
for a procedure. disconnects.
4 Severity Major Major Major
5 Probability Frequent Frequent Frequent
6 Hazard 12 12 12
Score
7 Action Control Control Control
(Eliminate,
Control, or
Accept)
MISSED ALARMS 6

8 Description Ensure proper skin Develop checklist for Establish protocol for
of Action preparation. Establish hand off between staff. periodic sensor
protocol for periodic Establish protocol for inspection and
sensor inspection and periodic sensor replacement. Place
replacement. Trial inspection and bedside alarm in a spot
different sensors that replacement. Establish that is not easily
work better. protocol for placing accidentally
patient back on disconnected from
continuous monitoring. power source. Place
power cord in a spot
out of reach of patient.

1 Process Step 1. Alarm page sent to bedside nurse

2. Flashing green light outside patient room
3. Display and tone of nursing station console changes
2 Potential Bedside nurse is not Staff is too far from the Delay in intervention.
Failure carrying pager patient room to hear
Mode bedside alarm or see
flashing green light
outside patient room
3 Potential Nurse forgot to carry Challenging The nurse is unable to
Cause(s) pager. Pager not architectural layout of leave another patient’s
handed off by unit. room.
previous nurse during
shift change.
Process Step #5

4 Severity Moderate Major Catastrophic

5 Probability Occasional Occasional Frequent

6 Hazard 6 9 16
Score
7 Action Accept Control Control
(Eliminate,
Control, or
Accept)
8 Description Establish protocol for Place displays in Clarify that every staff
of Action handoff of pager at strategic locations. member is responsible
shift change. Establish Require that alarm for responding to
protocol for reminding volume always be set at alarms. Establish tiers
nurses to carry pager adequate level. of backup coverage.
throughout shift. Configure system to Nurture culture that
Provide education and prevent alarm volume highly values
training on pager use from being turned teamwork.
and maintenance. down too low or off.
MISSED ALARMS 7

1 Process Step Vital signs exceed pre-set limit for 3 min and 15 sec
2 Potential Incorrect vital signs Patient is disconnected Bedside alarm
Failure displayed on bedside by a staff member to disconnected from
Mode monitor. move out of bed, but power source, thus no
not reconnected upon alarm.
return to bed.
3 Potential Improperly placed or Patient needs to go to Accidental
Cause(s) disconnected sensors the restroom, patient disconnection. Patient
due to sweat. needs to be transported purposefully
for a procedure. disconnects.
4 Severity Major Major Major
5 Probability Frequent Frequent Frequent
Process Step #6

6 Hazard 12 12 12
Score
7 Action Control Control Control
(Eliminate,
Control, or
Accept)
8 Description Ensure proper skin Develop checklist for Establish protocol for
of Action preparation. Establish hand off between staff. periodic sensor
protocol for periodic Establish protocol for inspection and
sensor inspection and periodic sensor replacement. Place
replacement. Trial inspection and bedside alarm in a spot
different sensors that replacement. Establish that is not easily
work better. protocol for placing accidentally
patient back on disconnected from
continuous monitoring. power source. Place
power cord in a spot
out of reach of patient.

1 Process Step 1. Urgent page sent to bedside and charge nurse

2. Flashing green and white light outside patient room
3. Display and tone of nurse station console changes to double rate
Process Step #7

2 Potential Both bedside and Staff are too far from Delay in intervention.
Failure charge nurse forget to the patient room to hear
Mode carry pager bedside alarm, see
flashing green light
outside patient room,
hear nurse station
console tone change to
double rate
MISSED ALARMS 8

3 Potential Nurse forgot to carry Challenging Both bedside nurse

Cause(s) pager. Pager not architectural layout of and charge nurse
handed off by unit. unable to leave
previous nurse during another patient.
shift change. Staffing issues.
4 Severity Major Major Catastrophic
5 Probability Uncommon Occasional Occasional
6 Hazard 6 9 12
Score
7 Action Accept Control Control
(Eliminate,
Control, or
Accept)
8 Description Establish protocol for Place displays in Clarify that every staff
of Action handoff of pager at strategic locations. member is responsible
shift change. Establish Require that alarm for responding to
protocol for reminding volume always be set at alarms. Establish tiers
nurses to carry pager adequate level. of backup coverage.
throughout shift. Configure system to Nurture a culture that
Provide education and prevent alarm volume highly values
training on pager use from being turned teamwork.
and maintenance. down too low or off.

1 Process Alarm deactivated

Step
2 Potential Equipment failure: Equipment failure: Equipment failure:
Failure alarm page not sent to alarm does not activate alarm does not
Mode bedside or charge nurse light outside patient activate nurse station
room console tone change
Process Step #8

3 Potential Malfunctioning Malfunctioning Malfunctioning

Cause(s) equipment. Signal loss. equipment. Signal loss. equipment. Signal
Electromagnetic Electromagnetic loss. Electromagnetic
interference. interference. interference.
4 Severity Catastrophic Catastrophic Catastrophic
5 Probability Uncommon Uncommon Uncommon
6 Hazard 8 8 8
Score
7 Action Control Control Control
(Eliminate,
Control, or
Accept)
MISSED ALARMS 9

8 Description Verify patient Verify patient Verify patient

of Action physiologic waveforms physiologic waveforms physiologic
and numbers at the and numbers at the waveforms and
central station. Require central station. Require numbers at the central
staff to ensure all staff to ensure all station. Require staff
connections on bedside connections on bedside to ensure all
alarm are intact at the alarm are intact at the connections on
beginning of the shift. beginning of the shift. bedside alarm are
Perform periodic Perform periodic intact at the beginning
inspection of inspection of of the shift. Perform
equipment by equipment by periodic inspection of
engineering engineering equipment by
professionals. professionals. engineering
professionals.