Case Study – Noncompliance

Read the article, “Alarm Fatigue Sets Off Bells: Mass. Incident Highlights Need for Protocols Check” in regards to noncompliance. In a 2 to 3 page paper, discuss the following:What regulatory agencies were involved in the disciplinary action?What incident or series of incidents resulted in noncompliance?What were the penalties and consequences?What steps should have been taken to avoid/prevent this type of noncompliance?APA FORMAT with references
proquestdocuments_2018_04_24.pdf

Unformatted Attachment Preview

Don't use plagiarized sources. Get Your Custom Essay on
Case Study – Noncompliance
Just from $13/Page
Order Essay

Alarm fatigue sets off bells
McKinney, Maureen . Modern Healthcare ; Chicago Vol. 40, Iss. 15, (Apr 12, 2010): 14.
ProQuest document link
ABSTRACT
After a recent CMS report ruled that nurses’ desensitization to monitor alarms played a role in the death of a
cardiac patient, more hospitals are taking heed and examining the problem, known as alarm fatigue, in their own
organizations. A review of cardiac monitor logs showed that during a 20-minute period, the patient’s heart rate
dropped rapidly and eventually stopped, and subsequent resuscitation efforts were unsuccessful. Alarm fatigue is
not unique to Massachusetts General. The increasing focus on alarm fatigue is just one part of a larger trend of
patient-safety awareness, said Andrea Kline, pediatric nurse practitioner at Riley Hospital for Children, part of
1,385-bed Clarian Health Partners, Indianapolis.
FULL TEXT
Headnote
QUALITY
Mass. incident highlights need for protocols check
After a recent CMS report ruled that nurses’ desensitization to monitor alarms played a role in the death of a
cardiac patient, more hospitals are taking heed and examining the problem, known as alarm fatigue, in meir own
organizations.
The incident occurred on an early January morning at 907-bed Massachusetts General Hospital, Boston. The
patient was one of 31 others on a surgical floor staffed by 10 nurses, according to the April 2 report. A review of
cardiac monitor logs showed that during a 20minute period, the patient’s heart rate dropped rapidly and eventually
stopped, and subsequent resuscitation efforts were unsuccessful.
Nurses did not report hearing repeated warning alarms, and the volume on the patient’s bedside crisis alarm, which
alerts staff to an arrhythmia, was in the “off” setting, said Gregg Meyer, Massachusetts General’s senior vice
president for quality and safety.
The event highlighted a number of significant problems, including the discovery that scrolled volume functions on
bedside alarms had an off setting that could be applied easily and inadvertently – something that was not wellknown among staff, Meyer said.
Despite the tragedy, Meyer said he was pleased the staff had followed proper protocol for a serious safety event
Nurses on the floor immediately completed a report and notified administrators, who then alerted the state’s public
health department.
Officials from the CMS knew of the event already when they arrived at Massachusetts General in February for a
random validation survey, and they were able to examine the incident in detail while at the hospital, said Roseanne
Pawelec, spokeswoman for the CMS’ regional office.
“CMS did not uncover a rock during their survey,” Meyer said. “We had already shared this openly.”
Since the incident, the staff at Massachusetts General has disabled the off setting on more than 1,100 monitors,
installed distributed speakers so volume settings on alarms do not have to be turned up so high, standardized
alarm volumes, and instituted a review process for any changes to default settings. Additionally, the staff has
created a training program that reviews monitor technology, and has formed a committee charged with creating
best practices and standards for alarm use, said Jeanette Ives Erickson, senior vice president for patient care and
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 1 of 4
chief nurse at the hospital.
“The team is reviewing standards to see which patients really need to be on monitors,” Meyer said. “We have
immediately seen more discussion at the unit level, and we’ve discovered it’s a topic that needs to be part of
shiftto-shift handoff conversations.”
Alarm fatigue is not unique to Massachusetts General. Several years ago, prompted by a fear that excessive
alarms had desensitized nursing staff, 925-bed Johns Hopkins Hospital, Baltimore, began a quality improvement
project, the results of which were published in the January issue of the American Journal of Critical Care.
The findings were eye-opening, said Maria Cvach, assistant director of nursing, clinical standards, and co-author of
the article. The hospital’s medical progressive care unit had a staggering 500 alarms per patient per day – most of
which I were low-priority and required no intervention, but made for a very noisy environment, she said, Through
the improvement program, the hospital was able to reduce that number to 200.
The key, said Cvach, is setting realistic, actionable alarm parameters based on your patient population. For
instance, if a unit has a large number of respiratory patients with chronic lung disease, it’s not productive to set
alarms on pulse oxygenation monitors based on normal lung-function values.
Cvach also advised creating some kind of backup system to provide a safeguard against errors. Some hospitals
deliver an additional notification via pager, cell phone or marquee sign. Others have taken an extra step and added
a monitor technician whose job is to serve as an extra pair of eyes and make sure lethal rhythms or deteriorating
status do not go unnoticed.
The increasing focus on alarm fatigue is just one part of a larger trend of patient-safety awareness, said Andrea
Kline, pediatric nurse practitioner at Riley Hospital for Children, part of 1,385-bed Clarian Health Partners,
Indianapolis. Earlier this year, while working at 247-bed Children’s Memorial Hospital, Chicago, Kline developed a
24-question survey on alarm fatigue, sent it to 300 critical-care nurses at 681 -bed Rush University Medical Center,
Chicago, and presented results from the 94 responses she received at the Society of Critical Care Medicine’s
annual Critical Care Congress in January.
The survey indicated that alarms were often not set appropriately for patients, and nurses often worried about
unintentionally missing one, Kline said.
Despite receiving more attention in the past few months, alarm fatigue was on the Joint Commission’s radar in
2003 when it named it as one if its National Patient Safety Goals, said Paul Schyve, the organization’s senior vice
president. It was deleted in 2005 because reports had improved significantly, he said, but that trend has changed
and the numbers are creeping back up once again. A constant stream of alarms can easily lead to fatigue, Schyve
said, drawing an analogy to the frequent alerts often present in computerized physician order-entry systems.
There were two parts to the initial 2003 patient-safety goal regarding alarm fatigue: regular maintenance and
ensuring alarm volumes were set high enough. In 2004, there were nine reports of noncompliance from surveyors;
that number has since climbed to more than 30.
At Massachusetts General, transparency and quick action has helped make the best out of a very unfortunate
situation, Erickson said.
“We know this is a national issue and something that happens at other hospitals,” Meyer said. “It has galvanized us
to look at our culture, make improvements in our processes, i and do the right thing for our patients.”
Sidebar
Alarm fatigue can occur when nurses work In excessively noisy environments or face high numbers of low-priority
alerts.
DETAILS
Subject:
Monitoring systems; Patient safety; Hospitals; Nurses; Deaths
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 2 of 4
Location:
United States–US
Company / organization:
Name: Massachusetts General Hospital-Boston; NAICS: 622110
Classification:
9190: United States; 8320: Health care industry
Publication title:
Modern Healthcare; Chicago
Volume:
40
Issue:
15
Pages:
14
Number of pages:
1
Publication year:
2010
Publication date:
Apr 12, 2010
Section:
The Week in Healthcare
Publisher:
Crain Communications, Incorporated
Place of publication:
Chicago
Country of publication:
United States, Chicago
Publication subject:
Medical Sciences, Health Facilities And Administration
ISSN:
01607480
CODEN:
MOHEDA
Source type:
Trade Journals
Language of publication:
English
Document type:
News
Document feature:
Photographs
ProQuest document ID:
211892860
Document URL:
http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocv
iew%2F211892860%3Faccountid%3D27965
Copyright:
Copyright Crain Communications, Incorporated Apr 12, 2010
Last updated:
2011-07-27
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 3 of 4
Database:
ProQuest Central
LINKS
Linking Service
Database copyright ? 2018 ProQuest LLC. All rights reserved.
Terms and Conditions
Contact ProQuest
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 4 of 4

Purchase answer to see full
attachment

GradeAcers
Calculate your paper price
Pages (550 words)
Approximate price: -

Why Work with Us

Top Quality and Well-Researched Papers

We always make sure that writers follow all your instructions precisely. You can choose your academic level: high school, college/university or professional, and we will assign a writer who has a respective degree.

Professional and Experienced Academic Writers

We have a team of professional writers with experience in academic and business writing. Many are native speakers and able to perform any task for which you need help.

Free Unlimited Revisions

If you think we missed something, send your order for a free revision. You have 10 days to submit the order for review after you have received the final document. You can do this yourself after logging into your personal account or by contacting our support.

Prompt Delivery and 100% Money-Back-Guarantee

All papers are always delivered on time. In case we need more time to master your paper, we may contact you regarding the deadline extension. In case you cannot provide us with more time, a 100% refund is guaranteed.

Original & Confidential

We use several writing tools checks to ensure that all documents you receive are free from plagiarism. Our editors carefully review all quotations in the text. We also promise maximum confidentiality in all of our services.

24/7 Customer Support

Our support agents are available 24 hours a day 7 days a week and committed to providing you with the best customer experience. Get in touch whenever you need any assistance.

Try it now!

Calculate the price of your order

Total price:
$0.00

How it works?

Follow these simple steps to get your paper done

Place your order

Fill in the order form and provide all details of your assignment.

Proceed with the payment

Choose the payment system that suits you most.

Receive the final file

Once your paper is ready, we will email it to you.

Our Services

No need to work on your paper at night. Sleep tight, we will cover your back. We offer all kinds of writing services.

Essays

Essay Writing Service

No matter what kind of academic paper you need and how urgent you need it, you are welcome to choose your academic level and the type of your paper at an affordable price. We take care of all your paper needs and give a 24/7 customer care support system.

Admissions

Admission Essays & Business Writing Help

An admission essay is an essay or other written statement by a candidate, often a potential student enrolling in a college, university, or graduate school. You can be rest assurred that through our service we will write the best admission essay for you.

Reviews

Editing Support

Our academic writers and editors make the necessary changes to your paper so that it is polished. We also format your document by correctly quoting the sources and creating reference lists in the formats APA, Harvard, MLA, Chicago / Turabian.

Reviews

Revision Support

If you think your paper could be improved, you can request a review. In this case, your paper will be checked by the writer or assigned to an editor. You can use this option as many times as you see fit. This is free because we want you to be completely satisfied with the service offered.

Order your essay today and save 15% with the discount code DISCOUNT15