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July 2013 Archive for High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

The alarming world

Jul 17, 2013 | Comments (0) | 13953 Views

By Ronald M. Wyatt, M.D., M.H.A.
Medical Director
The Joint Commission

Ronald M. Wyatt, Medical Director, The Joint CommissionAs more medical devices are being connected to patients, the opportunities for patient harm increase. A typical critical care unit has over 150 alarms per patient per day. Many alarm-based devices are not standardized or there is inconsistent use of alarms.

Medical alarm fatigue has been identified by The Joint Commission as a major contributing factor in 80 deaths, 13 patients with permanent loss of function, and five patients who required unexpected additional care or extended stays, from June 2009-June 2012. Thus, the impact of alarm hazards is having a devastating impact on patients and their families. It is estimated that 85-99 percent of alarms do not lead to required clinical interventions. This is a complex problem but solutions do exist and this must become a “front page” issue. Clinician awareness and buy-in are critical success factors.

With so many alarms per patient per day, it is no surprise that this leads to alarm fatigue. Clinicians become desensitized, overwhelmed or immune to medical device alarms.

ECRI Institute has set alarm hazards as a top priority for patient safety. It is crucial that institutions make assessments of specific patient areas and understand what the clinical staff thinks about alarm safety. This means understanding why fatigued clinicians may turn down alarm volumes, adjust alarm settings, or turn the alarm off – each of which may result in fatal consequences.

The Joint Commission, ECRI Institute and the Association for the Advancement of Medical Instrumentation (AAMI) recommend:

  1. Ensuring there is a process for safe alarm management and response
  2. Preparing an inventory of alarm-equipped medical devices
  3. Establishing guidelines for tailoring alarm settings and limits for individual patients
  4. Inspecting, checking and maintaining alarm-equipped devices.


Additional information is available at ECRI Institute’s Alarm Safety Resource Site and The Joint Commission’s recently released Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals.

Saving lives in emergencies takes planning and training

Jul 02, 2013 | Comments (0) | 6064 Views

By Daniel J. Castillo, M.D., M.B.A.
Medical Director
The Joint Commission

Every second counts. I have heard that phrase uttered often, especially during my training as an emergency medicine physician. There are clinical cases where quick, decisive action must be taken in order to save a person’s life. Fortunately, many of these cases occur infrequently, but this perceived benefit introduces the predicament of preparedness for the uncommon presentations. In these situations, simulation education helps prepare physicians to treat patients quickly and appropriately. I will never forget the night I was working in the Emergency Department, one of my first as an attending, and a 16-year-old female came in with acute anaphylaxis. She had been out to dinner with friends and made the innocent mistake of sharing food at a Thai restaurant even though she had a severe peanut allergy.  Within seconds she could barely breathe due to the swelling in her throat. Luckily, the restaurant was just down the street from the ED, and she got to me within minutes of symptom onset. I was able to perform the duties that eventually saved her life, in large part, due to the simulated exercises I had completed during residency.  
Every second counts. That phrase took on additional meaning when reading and listening to interviews of the medical staff that took care of victims of the recent Boston Marathon bombing. I, like many others who read the stories, was amazed by how quickly the Boston EMS and Hospital Systems responded to the tragedy. Lives and limbs were literally saved because of the Boston medical community’s preparedness for the uncommon. I was especially struck by an interview in Bloomberg Businessweek, with Dr. Paul Biddinger, the medical director for emergency preparedness at Massachusetts General. He happened to be working at one of the medical tents set up along the marathon to offer care to the runners. He stated:

“We can clearly point to a couple of people who went to the operating room first – truly minutes mattered, If this hadn’t gone smoothly – from the marathon itself, to the transport, to the care in the hospital – had not every single step been perfect, they would have died. Overall I would like to think we saved limbs and lives, but there is no question that we have a couple of people that lived because the system worked the way it did.’’ 

The question must then be asked: How do we prepare for such uncommon, urgent events?

The solution lies within simulated exercises. The Joint Commission, as part of its Emergency Management chapter, outlines processes that must be in place to help manage these rare, yet catastrophic events. The elements of the chapter have been built over the years by gathering experts in the field as well as communicating with and learning from organizations that have previously had to mitigate these disasters. The emphasis is on planning. Planning allows the organization, along with its community, to put together a comprehensive Emergency Operations Plan (EOP) that can then be tested several times each year. The results of these simulated exercises must then be analyzed and learned from.  Fortunately, these tragic events are uncommon, but it is only through training that we can be prepared, and preparedness is crucial when every second counts.