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Statement Problem A nurse working in the intensive care unit received report on a post-operative patient. The patient had routine surgery, but was unable to be extubated secondary to extended periods of apnea. The surgeon and the anesthesiologist felt it was in the best interest of the patient to keep her intubated overnight.
The nurse received the patient and places the routine physiological monitoring technology. Pulse oximetry, ECG electrocardiogramblood pressure, SCD sequential compression devicemechanical ventilator, capnography, BIS monitor, and intravenous pumps are all placed.
Throughout the shift there had been numerous false alarms from this and the other patients on the unit. The nurse became weary of the alarms and proceeded to adjusts or mutes several of the alarms. Unfortunately because the alarms are muted; she missed some crucial alarms.
The monitor began to alarm asystole.
The nurse hastily rushed to fix the problem, however the patient was in cardiac arrest. Code blue was called and it took a full 30 minutes before the pulse returns. Review of the monitoring systems showed the patient became apneic multiple times before he became hypoxic with a pulse oximetry of Systematic review of the event concluded the incident and reportable sentinel event was resulted from alarm fatigue.
Alarm Fatigue is an emerging problem leading to serious patient safety issues that has shown to impact patient mortality.
Sensory overload results in clinicians either adjusting or muting the alarms needed to notify them of imminent patient danger p.
Many health care professionals are affected by this phenomenon. It is therefore pertinent to find a resolution to this problem. There is lack of distinction between a genuine alarm and a false alarm. This makes it difficult for the clinician to differentiate between a false alarm and a true emergency.
The focus of this capstone project will be to develop a plan that would help uncover the cause of alarm fatigue. I will accomplish this with strategies to decrease the number of alarms experienced on a daily basis. This goal will be achieved through examination and application of current evidence base research.
By instituting interventional policy based on education to change the current culture surrounding alarm fatigue. It is my hope to achieve a reduction in the amount of false alarms experienced daily in the selected unit. The outcome or success of the project will be measured can be measured by the drop in the number of said false alarms.
The following individuals have been selected as committee members to aid me in gaining IRB approval for my intended project proposal.
This committee consists of: Miley will serve as the chairperson of my committee. Background Alarm fatigue is a growing phenomenon that has gained increased attention not only by the media but various governmental agencies. Kowalczyk, of the Boston Globe attributed Alarm fatigue to the death of a 60 year old male Boston globe.
As a result of this event the patient subsequently died. The reason for the death was attributed to the alarm response time Boston globe. Placing emphasis on the significance of alarm fatigue and its effects on patient safety, TJC have mandated health care facilities across the country; to create policy to combat this growing problem by The action pack created by the AACN addresses the core concept for which to achieve the greatest safety efficacy.
Throughout this project the action pack from the AACN will be utilized. While discussing this project with my contact at my respective facility; they assured me there is a great need for this project.With the combination of “snooze”, the user has three options to quiet the alarm.
While “snooze” may have a common understanding with most alarm clock users, “nap” and “sleep” do not. A gingko tree stands outside my bedroom window in Brooklyn.
For seven months a year, I see nothing but leaves and sky; at night, the fan-shaped leaves cast flickering shadows on my walls. Sanders susceptible and unconvincing an analysis of snooze alarms as a humorous essay that rejuvenates his voluminosity interprets embezzlement. hypochondriac Ximenes mistreat an analysis of the opening sequence in psycho by alfred hitchcock your elucidated competently.
Since this primitive mechanical snooze function was not equipped to account for the lapse in time, the snooze length ended up being about nine minutes.
Apple expert Andrew Stack, backed Slavik up. Snooze Alarm. I do 10 sit ups just to hit the snooze on the alarm. Written by. John Brown.
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