IMPROVING MEDICAL SAFETY BY REDUCING FALSE ALARMS ASSOCIATED WITH ELECTROCARDIOGRAM MONITORS

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  • HAGA Hiromi
    Showa University School of Nursing and Rehabilitation Sciences Department of Nursing, Showa University Fujigaoka Hospital
  • OSAKI Chieko
    Showa University School of Nursing and Rehabilitation Sciences

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Other Title
  • 心電図モニターのテクニカルアラーム低減による医療安全への取り組み
  • 臨床報告 心電図モニターのテクニカルアラーム低減による医療安全への取り組み
  • リンショウ ホウコク シンデンズ モニター ノ テクニカルアラーム テイゲン ニ ヨル イリョウ アンゼン エ ノ トリクミ

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Description

The aim of this study was to avoid medical errors due to delays in responding to alarms, by providing nurses with safety education and structuring a new management system in order to reduce the technical alarms of electrocardiogram monitors （hereinafter, called monitors） in the general ward of acute care hospitals. We provided safety education regarding monitor alarms, structured a new monitor management system and thoroughly implemented it among 33 nurses working in ward B of hospital A （40 beds）. The contents of the safety education included items such as the necessity of attaching monitors and setting alarms, the basic settings of monitors, and proper electrode control. As a new monitor management system, we reviewed the monitor management standards, clarified the alarm setting standards, and regularly checked the alarm setting conditions of the lower and upper limits, in addition to appointing a monitor and alarm surveillant. Three factors were involved in measuring the effects of the method: 1） the frequency of the occurrence of technical alarms that have accumulated in the monitor device; 2） the rate of using a checklist for monitor management （hereinafter, called the checklist）; and 3） the number of incidents/accidents related to the delay in alarm response. We compared these factors before and after the study. The rate of using the checklist increased from 78.6％ to 98％. Technical alarm occurrence declined by 55％. There was no incident due to the delay in responding alarms and accidents decreased markedly from four to zero from the previous year. Safety education and structuring a new management system in order to reduce technical alarms reduced alarms that do not require immediate intervention and facilitated responses for urgent alarms, leading to the prevention of medical errors due to delays in responding to alarms.

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