Capstone Project for Undergraduate BSN

1. Preventing
Alarm Fatigue
by Bax, Crutcher, & Engel

2. Populations
● Post-Intensive (PINS) Unit
● Medical/Surgical Unit
● Orthopedic/Neurology Unit

3. Problem
● Nurse Desensitization 4
○ Alarm sensory overload causing nurses to tune out
or miss potentially hazardous patient alarm events
○ Decreases patient safety
● Nuisance Alarms 7
○ Non-emergent and taking time from patient cares
○ Result in nurses turning down, silencing, or
adjusting alarm parameters outside of limits

4. Problem
● Potential Hazards and Sentinel Events
○ 98 reported events: 80 deaths, 18 permanent loss of
function, 5 with extended care and length of stay 4
● Recognized by Joint Commission (JCAHO)
○ National Patient Safety Goal (NSPG.06.01.01) 5
■ “Improve the Safety of Clinical Alarm Systems”
■ Effective January 1, 2014

5. Desired Outcomes
● Clinical
○ Reduce alarm fatigue and nurse desensitization in
order to increase patient safety
● Quality
○ Promote a quiet healing environment for the patient
● Cost
○ Reduce sentinel events and length of stay costs

6. Best Practice Action Plan
● Telemetry Task Force 6
○ Monthly huddles to discuss evidence-based practice
○ Create safe alarm protocols and policies
● Educate Nurses
○ On effects of alarm fatigue and types of alarms
○ To set safe individualized patient alarm parameters
○ Monthly training sessions and online modules

7. Best Practice Action Plan
● “Smart Alarms” 2
○ Account for signal quality, rate of change, and
patient sensitivity
○ Add short delays to decrease nuisance alarms
● Extension Evaluate 3
○ System to gather baseline alarm data for 30 days
○ Records time, type of alarm, reason for alarming, and
number of alarms

8. Evaluation of Action Plan
● Extension Evaluate 3
○ To gain a repeat 30 day alarm assessment post-
implementation for comparison
● Telemetry Task Force Meetings 6
○ Monthly to evaluate the effectiveness of new alarm
policies, protocol implementation, staff education,
and the understanding of “smart alarms”

9. Evaluation of Action Plan
● Clinical Alarms Survey
○ Provided to all health professionals
○ Results direct staff educational needs, policy
adjustment, and identify equipment changes
● Failure Mode Effects Analysis (FMEA)
○ Annually and as needed
○ Ensures alarm audibility, visibility, and proper
equipment function

10. Human Resources
● Telemetry Task Force 6
○ Physicians, nurses, quality inspector, staff educator,
supply management, and a clinical engineer
● Monthly Meetings for Education and Training 4
○ Educate nurses and other health professionals
○ Release updates on protocols and policies from new
evidence-based practice

11. Technology and Equipment Resources
● Extension Evaluate System 3
● “Smart Alarms” 6
● Employee computers, demonstration equipment,
and evidence-based research for staff education and
training

12. Financial Resources
● Organizing and funding staff participation in
ongoing monthly training sessions 4
● Budget for new technology and “smart alarms” 6
● Afford the Extension Evaluate System 3

13. Barriers and Solutions
● No single answer to a complex problem
○ Staff realization of their vital role in alarm fatigue
● Staff participation and lack of buy-in
○ Bimonthly meetings and quizzes
● Lack of finances
○ Create a budgeting timeline for implementation