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If Unanswered Device Alarms Aren’t a ‘Never Event’, How Can We Monitor Close Misses and Prevent Future Deaths?

Introduction: 

The ‘Never Event’ label in healthcare refers to incidents that should not occur if proper measures are taken. Though unanswered device alarms haven’t been termed as such, their significant risks cannot be sidelined. So, what measures can we employ to monitor and record ‘close misses’ associated with these alarms?  

  1. Understanding the Implications of Alarms:
  • Differentiating Alarm Types: Continual education and retraining of healthcare staff on diverse alarms, their urgency, and appropriate responses are indispensable. 
  • Recognising the Perils of Alarm Fatigue: It’s essential to tackle ‘alarm fatigue’, where frequent alarms desensitise staff. Strategic reductions of non-critical alarms can help combat this fatigue. 
  1. Embracing Comprehensive Monitoring Systems:
  • Leveraging Technological Solutions: Platforms like BEAMS by Tutum Medical offer sophisticated solutions for acoustically monitoring alarms and alerting healthcare professionals, ensuring that every alarm receives attention. 
  • Utilising Accurate Reporting Systems: Employ robust reporting mechanisms to maintain a log of all alarms and their subsequent responses, facilitating real-time surveillance and analysis. 
  1. Formal Reporting Mechanisms for Close Misses:
  • Establishing an Alarm Response Registry: Just as with incident reporting, an alarm response registry can be set up. Here, ‘close misses’ are meticulously documented, ensuring data is primed for subsequent review. 
  • Promoting an Atmosphere of Transparent Reporting: Encourage healthcare workers to report close misses without the looming fear of punitive repercussions. This not only enhances patient safety but nurtures trust within the organisation. 
  1. Rigorous Review and Analysis:
  • Audit of All Alarm Response Times: Periodic examinations of alarm logs, coupled with a study of response times, can shed light on potential pitfalls, guiding rectifications. 
  • Implementing Root Cause Analysis: For especially concerning close misses, conduct an in-depth root cause analysis. This helps decipher the underlying factors and facilitates the inception of corrective actions. 
  1. Collaborative Workshops and Training:
  • Scenario-Based Training: Facilitate frequent training sessions built around real-life scenarios. These sessions reinforce the severity of situations and groom staff for emergencies. 
  • Forge Ties with Tech Providers: Engage actively with technology solution providers like Tutum Medical to ensure systems remain up-to-date and resonate with the hospital’s unique requirements. 

Conclusion: 

The repercussions of unanswered device alarms, while not tagged as a ‘Never Event’, are undeniably severe. By harnessing technological advances, encouraging transparent communication, and consistently refining training protocols, we can guarantee that every alarm translates to timely and life-saving care. 

If you’d like to talk to us about BEAMS, to ensure alarm receives attention, please feel free to contact us. We’d be happy to have a chat.  

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