Improving Telemetry

Web Exclusive Sept/Oct 04

W5-13

Improving Telemetry Alarm Response to
Noncritical Alarms Using a Failure Mode
and Effects Analysis
Donita Semple, BS RN CPHQ; Linda Dalessio, RN APN CCRN

The literature suggests nurses working in
telemetry units across the country become
desensitized to alarm sounds, particularly to
tones associated with noncritical events.
Noncritical alarms may betriggered not only by
patient activity but also by the inadvertent
removal of a monitoring lead. Because a number
of critical events may be related to removal of a
lead, it was determined this may result in a significant patient safety issue.
A sophisticated, state-of-the-art, and reliable cardiac monitoring system was purchased in August 2002. The monitor display
provides changes in thebackground screen
color, from blue (low level), to yellow (moderate level), to red (high level), as well as sounds
three separate and distinct alarm tones to signal the healthcare provider regarding the critical nature of the event and the urgency for
nursing intervention.
A failure mode and effects analysis (FMEA)
was selected to evaluate the current practice,
identify areas of vulnerabilityto an adverse
event, and eliminate failures before they happen following two similar events related to
patients removing their own leads and the
nonrecognition of possible critical dysrhythmias. Immediate action following these events
included education of the staff and an increase
in the tone of the low-level alarms. The overall
goals of this process was to seek long-term
solutions and toavoid future occurrences.

Implementation
A team was assembled, and work proceeded carefully though the 10-step FMEA process.
The team was aware this risk assessment
method had proven useful to the manufacturing, computer software design, and the aviation industries and now had been advocated
for use in the healthcare system (Spath, 2003).
The team leaders, with the support of the
hospitaladministration, were careful to select

Telemetry units are used extensively for the monitoring of
recovering cardiac patients who no longer require the critical care environment. Because of patient mobility, monitoring leads may come off, cause artifact, or be inadvertently removed without the patient having an adverse cardiac event. Sophisticated monitoring systems in telemetry
units allowfor different alarm levels and tones. Nursing
care providers often become desensitized to noncritical
alarm signals, increasing the likelihood that a true critical
event will not be recognized and responded to promptly.
Various methods have been employed in hospitals to
address the recognition of and prompt response to clinical
alarms. We determined this to be a high-risk issue at thefacility—timely response was critical to the safety of
patients. Before initiation of the failure mode and effects
analysis (FMEA), the response time to noncritical cardiac
alarms was 12 minutes. Following implementation of
changes provided by the FMEA, response time decreased to
1.57 minutes.
team members who were comfortable sharing
their experiences and ideas and were close to
the processbut could still separate their “war
stories” from the usual unit procedures.
Membership represented all shifts with preference given to staff who were willing to commit
to participation in weekly team meetings. The
director of clinical engineering, the unit manager, and three additional nurses from the
telemetry unit were selected to participate on
the team.
From the beginning, everyoneseemed
excited to explore and improve this process
with an ultimate goal of improving the
response time for “low-level, noncritical” cardiac alarms. Following an overview of the
process, the team felt comfortable with a justin-time or learn-as-you-go education model.

Key Words
evaluation
FMEA
outcomes
performance
improvement
teams

JHQ Online, Sept/Oct, pp. W5-13 to W5-19.
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