Close to 100 clinicians, healthcare technology experts, regulators, patient safety advocates, researchers, and leaders in the medical device industry gathered last week in Arlington, VA, to kick off an unprecedented two-year initiative to improve alarm management in healthcare.
The inaugural meeting of the National Coalition for Alarm Management Safety, an effort launched by the AAMI Foundation’s Healthcare Technology Safety Institute (HTSI), brought together these experts to hear both the experiences of seven hospitals that have worked to improve alarm management and the perspectives of industry leaders, as well as to begin the discussion of what is needed to become a “high-reliability organization,” one in which systems are in place to radically reduce failures. The presentations sparked lively discussions, and attendees identified several areas worthy of follow up, including a need for additional research to determine if adverse patient outcomes have resulted from enhanced alarm parameters for clinical monitors.
“The outcome was a commitment by all coalition members to continue to generate the knowledge needed, both from clinical experience and clinical-trial data, to improve alarm management,” said Marilyn Neder Flack, executive director of the AAMI Foundation and senior vice president of Patient Safety Initiatives at AAMI. “This is just the beginning.”
One topic that generated particular interest related to developing and publishing best practices. Some attendees thought the process should rely on data already generated in the clinical environment, while others favored a nationwide clinical trial to gather additional evidence.
The meeting concluded with a commitment by coalition members to continue working together to improve alarm management, building on the lessons learned from the presentations. Many acknowledged that a lot of work remains. “We should be more patient-outcome focused,” said Mark Heston, operations director at the Cleveland Clinic. “It’s also interesting how many people are affected by alarms: patients, visitors, staff, physicians, device manufacturers, healthcare technology management professionals—the list goes on and on.”
Representatives from medical device manufacturers affirmed their commitment to working with healthcare to enhance patient safety, particularly in the area of how to manage default settings on alarms.
Over the course of the year, 18 other hospitals involved in the project will share their experiences via monthly webinars. Although the coalition only will include 25 hospitals during the initial stages, other facilities will be invited to share data as the project moves forward.
The tangibles the coalition plans to deliver over the next year include the following:
- A compendium of recommendations based on HTSI-produced alarm webinars and white papers, known collectively as the Safety Innovations series
- A list of recommended enhancements for the medical device industry to build into future software and product versions
- A compilation of aggregated parameter data supplied by the member hospitals
- Educational tools to teach clinicians about alarm settings and how to customize these settings for each patient
Over the next two years, the coalition hopes to produce a list of suggestions on how hospitals can become high-reliability organizations as devices and clinical-care processes evolve over time. Members also plan to write preliminary recommendations about the management of ventilator and infusion pump alarms.
HTSI would like to thank the industry sponsors that made this event and the future work of this coalition possible. The four Platinum Sponsors of the coalition’s work are Covidien, Extension Healthcare, GE Healthcare, and Philips Healthcare. The Gold sponsors are Baxter Healthcare, CareFusion, Cerner Corporation, Mindray, and Dräger Medical Systems, Inc, and the Silver Sponsors are B. Braun, EarlySense, Masimo Corporation, Sotera Wireless, and Spacelabs.