BlueSynergy Associates, LLC
  • Home
  • ABOUT
    • About You
    • About Us >
      • Twitter Feed
    • About DNV GL Healthcare
  • Services
    • Advising
    • Contract Auditing/Surveying
    • HIPAA / HITECH
    • Risk
    • Training/Education
  • Resources
    • Original Articles >
      • Accreditation Articles
      • Audits/Surveys Articles
      • Communication Articles
      • Cyber Risk / Cyber Security Articles
      • Education Articles
      • Medical Staff Articles
      • Process Articles
      • Risk Articles
      • Quality/Quality Tools >
        • ISO 9001:2015 FAQ's
    • Shared articles >
      • HBR article- Hospitals can't improve without better management systems
      • Becker's- 3 Ways hospitals can improve profitability in 2016
    • Past Newsletters (Progress Notes-PRN)
  • Tools
    • Prioritization Matrix
    • Heat Maps
    • Preliminary Risk Assessment
  • Revenue Cycle
  • Contact Us

alarm fatigue

5/24/2016

1 Comment

 
By: Jeff Harris, RPh

       In the mid 1960's, a man witnessed an awful multi-car pileup in San Francisco. That man also happened to have a PhD in psychology and was an inventor as well and he decided to do something about rear end collisions. The result was a third brake light installed at the top of the rear window in automobiles. Testing showed that the addition of the third light reduced rear end collisions by 50 to 60%.
Picture
Alerts designed to notify us of increased risk of an adverse outcome are all around us. My daughter's car has an indicator that notifies her when the tire pressure is low.

      I get a notification from my cell phone provider when our data limit is approaching. Arguably, the industry with the most alerts in in the modern hospitals. Physician order entry systems flag potential medication problems which is fine, but one study put the number of alerts physicians at one hospital must override to successfully input a medication at a whopping 17,000 per month. Pharmacists at the same hospital had to deal with 175,000 alerts per month. It sounds bad, until you consider a different study that looked at nurses in an ICU unit processing 381,560 alerts per month. That's 12,700 blinking, shrieking or otherwise annoying alerts 
a day. In one of the most understated examples of modern nomenclature, this is known as “alert fatigue”, which suggests it is an annoyance, rather that a safety issue.
 
       Clearly, it is a safety issue. A 2011 Boston Globe investigation found 200 deaths nationwide due to alarm fatigue. There are numerous case reports about heart monitors being turned off because of over-sensitive alarms followed by patient deaths because the alarm wasn't turned back on. It's easy to pass judgment in these cases, but how would you deal with 12,700 alarms to process in a day?
 
       The human brain is very good at blocking out distractions when immersed in a cognitive-heavy process. After so many overrides, a distraction is what they become. Software vendors and health care organizations are hesitant to reduce the level of alerts out of fear of liability. What would happen if, in the era of the “smart car”, the brake lights come on not when the brakes are applied, but when the algorithm decides they should come on to alert drivers behind the vehicle. Of course the auto companies would err on the side of caution, resulting in the lights being on for longer periods of time than before because of liability. How long would it take for the human brain to filter out this as a distraction? I'm thinking not very long.
 
Jeff Harris is a Pharmacist with over 25 years of leadership experience in hospital, retail, and home health environments. Due to a spinal cord injury, he is currently on long term disability.  Jeff is passionate about patient safety, risk management and cybersecurity issues in healthcare.  He continues to research and write about improving healthcare on a pro-bono basis. He can be reached by email at support@bluesynergyassociates.com. Follow BlueSynergy on LinkedIn and Twitter . 
1 Comment
Debra Olsen link
1/1/2021 06:25:45 am

Hello mate great bblog

Reply



Leave a Reply.

    Author

    We have a passionate vision to create meaningful change in healthcare by reducing risk and thereby providing a safer environment for patients.

    Archives

    December 2017
    January 2017
    October 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    December 2015
    November 2015
    October 2015
    September 2015

    Categories

    All

    RSS Feed

About You
About Us
Services
Education/Webinars
Resources
Blog
Contact Us

Call us toll free:
​1.844.424.7825

© 2016 BlueSynergy Associates, L.L.C.
  • Home
  • ABOUT
    • About You
    • About Us >
      • Twitter Feed
    • About DNV GL Healthcare
  • Services
    • Advising
    • Contract Auditing/Surveying
    • HIPAA / HITECH
    • Risk
    • Training/Education
  • Resources
    • Original Articles >
      • Accreditation Articles
      • Audits/Surveys Articles
      • Communication Articles
      • Cyber Risk / Cyber Security Articles
      • Education Articles
      • Medical Staff Articles
      • Process Articles
      • Risk Articles
      • Quality/Quality Tools >
        • ISO 9001:2015 FAQ's
    • Shared articles >
      • HBR article- Hospitals can't improve without better management systems
      • Becker's- 3 Ways hospitals can improve profitability in 2016
    • Past Newsletters (Progress Notes-PRN)
  • Tools
    • Prioritization Matrix
    • Heat Maps
    • Preliminary Risk Assessment
  • Revenue Cycle
  • Contact Us