The real cost of alarm fatigue - Help Net Security

Tom Benzoni benzonit at GMAIL.COM
Mon Sep 4 03:16:22 UTC 2017


Consider in your deliberations:
Cognitive load
Decision fatigue

Most of these alarms are known to be nonsense.
For example, the vast majority of people who say these are allergic to meds
are not allergic but intolerant or misinformed (another whole topic;
many patients are told they are allergic to an antibiotic because they
vomit or a relative is allergic.)
We persist in labeling patients with mild penicillin reactions (maybe no
reaction) as allergic to cephalosporins. We know this is nonsense but
health care systems buy these things because they were paid to so do.
Meanwhile, deep in these alerts are buried and indistinguishable data on
important items.

There is a simple solution: let the free market work. Don't pay the
software company unless I, the end user, attest that these programs work as
used (not as intended; they are not intended for human use. Read the fine
print; no FDA approval process.)

tom

On Sun, Sep 3, 2017 at 8:31 PM, robert bell <
0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:

> I like the acoustic engineer idea. I would like to find out what are the
> effects of various levels of hearing loss with and without background noise
> and while doing other defined tasks. What conditions do you need for
> hospital staff to compensate for all the sound problems and individual
> inattention issues. Similar to stethoscope use problems in medicine, should
> some people with certain hearing deficits not be allowed to work on ICU
> units? They may not be able to hear the alarms.
>
> It seems to me that there are so many things over which we could/should
> have control over, but currently are not controlled to reduce diagnostic
> error. Just think of lab tests, X-Ray/Radiological interpretations,
> communications, computer systems, etc. that all have errors that indirectly
> one way or another transfer to diagnostic errors.
>
> Don’t the diagnostic support systems have to be more accurate for the
> diagnostic errors to be more accurate? Don’t we have to work on the whole
> system together at once or tackle the support systems first to get it all
> right in the long term?
>
> This is an important aspect of the total problem and should be well, well
> discussed before it is too late. For example we spend 30 years perfecting
> diagnostic outcomes only to have a 20% error rate due solely to all the
> collective errors in the support systems! Would that be acceptable?
>
> Rob Bell, M.D.
>
>
>
> On Sep 3, 2017, at 3:22 PM, Peter Dayton MD <pdayton at COMCAST.NET> wrote:
>
> The issue is not that people are not airplanes. The issue is the human
> interaction with machines. Alarm fatigue is a real think. Cockpit Resource
> Management , CRM , is an  attempt to limit pilot workload to the essential
> functions and limit distractions.  I note a lot of monitoring devices in
> ICUs have audible alarms at the bedside but not remote alarms vis Bluetooth
> or Wi-Fi to a remote device with a silencing device at the bedside. ICUs
> are really not designed to isolate sound. It would be great to have an
> acoustic engineer study a typical ICU , design soundproofing and baffling
> to let patients have quiet without compromising the level of surveillance
> needed to care for them. Just a thought.
>
>
> Peter M. Dayton MD
> Medical Director of Patient Safety and Quality
> Martin Health Systems
> 1815 Kanner Highway
> Stuart FL 34994
> peter.dayton at martinhealth.org
> 772-285-4020 <(772)%20285-4020> cell
> 772-288-2999 <(772)%20288-2999> fax
> Our mission is to provide exceptional health care, hope and compassion to
> every person, every time.
> 1 Peter 3:15
>
>
>
> *From:* HM Epstein [mailto:hmepstein at GMAIL.COM <hmepstein at GMAIL.COM>]
> *Sent:* Saturday, September 2, 2017 7:13 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] The real cost of alarm fatigue - Help Net
> Security
>
> First of all Andrea, I'm so sorry you had to go through all of that. I
> hope they were able to identify the cause of the blood pressure drop so you
> don't have to deal with it again. Also, every patient needs rest. It is an
> essential part of the healing process. To have alarms going off repeatedly
> can't have helped. Nor feeling that your medical history was ignored.
>
> I often hear the comparisons drawn to the aerospace industry. It would be
> wonderful if we could get there but I wonder if we can. Humans are not
> airplanes and we don't respond the same way to, say blood pressure, the way
> an airplane responds to air pressure. Perhaps when precision medicine has
> been accurately applied to all diseases, we can have a better fix on what
> needs to be watched for in every patient.
>
> I'm wondering whether there are ways to code the alarms to match a
> patient's particular issue and medical history. Will the computer literate
> amongst us be able to tell me if we can create an algorithm to program the
> key elements of a patient's medical history and current situation in so
> that only certain alarms are sit on and, when necessary, triggered?
>
> Best,
> Helene
>
>
>
> On Sep 2, 2017, at 7:46 AM, Andrea Borondy Kitts <borondy at MSN.COM> wrote:
> I just had major surgery; right hip revision and left hip replacement. My
> blood pressure tanked and they were unable to control without meds so I had
> to spend 24 hours in ICU.
> Alarms went off every 5-10 minutes. They set my pulse alarm to 45 despite
> my advising them I typically run in the low 40's when at rest. It went off
> every 5 minutes and never triggered any action. After 8 hours of false
> alarms they finally changed it.
>
> A good model to use would be the aerospace industry. A lot of quality
> measures and design input are used to minimize false alarms for pilots and
> maintainers.
>
>
>
> Sent from my iPhone
>
>
> On Sep 1, 2017, at 11:13 PM, Lori Harmon <lharmon at SCCM.ORG> wrote:
>
> Here is an interesting article from *Critical Care Medicine* on this
> topic. SCCM is evaluating the opportunity for further study in intensive
> care units although we understand alarm and alert fatigue is not just a
> problem in the ICU care setting but is a larger patient safety issue house
> wide. And its not just sepsis either. This is a systems problem – someone
> had an aha moment that if we set an alarm or alert the clinicians would pay
> attention, but wait lets do that for everything and make the alarms and
> alerts sensitive to common clinical triggers so they go off all the time.
> It’s the Deming milky way syndrome. Something of importance to tackle.
>
> Lori
>
> *Lori A. Harmon, RRT, MBA* | Director of Quality | Society of Critical
> Care Medicine
> 500 Midway Drive, Mount Prospect, IL 60056-5811 USA
> t: +1 847.493.6403 <(847)%20493-6403> | m: +1 847.693.0359
> <(847)%20693-0359> | www.sccm.org
> <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.sccm.org&data=02%7C01%7Cjoyce.stout%40jefferson.edu%7C528b805b18b944b4b0f308d4ee3d5f83%7C55a89906c710436bbc444c590cb67c4a%7C0%7C0%7C636395394738676905&sdata=9yxZzHxVnBjtNmH2m6AmfT7qsJnYSxs%2BmyBDMYUR7ns%3D&reserved=0>
> www.facebook.com/SCCM1
> <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.facebook.com%2FSCCM1&data=02%7C01%7Cjoyce.stout%40jefferson.edu%7C528b805b18b944b4b0f308d4ee3d5f83%7C55a89906c710436bbc444c590cb67c4a%7C0%7C0%7C636395394738676905&sdata=C980NdXQswLhiMJZ8qdDaHFHoX%2FKVYef3BEq7xpPYog%3D&reserved=0>
>  | www.twitter.com/SCCM
> <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.twitter.com%2FSCCM&data=02%7C01%7Cjoyce.stout%40jefferson.edu%7C528b805b18b944b4b0f308d4ee3d5f83%7C55a89906c710436bbc444c590cb67c4a%7C0%7C0%7C636395394738676905&sdata=RgoqRhLIOaRcOUAB3tFaols8AdaEHIcPF3%2BQAap0j4o%3D&reserved=0>
>  | www.youtube.com/SCCM500
> <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.youtube.com%2FSCCM500&data=02%7C01%7Cjoyce.stout%40jefferson.edu%7C528b805b18b944b4b0f308d4ee3d5f83%7C55a89906c710436bbc444c590cb67c4a%7C0%7C0%7C636395394738676905&sdata=p8mKNhc%2FQDaI55MXHq4bAIEzHo0XMIP0pKXZbi3Tojg%3D&reserved=0>
>
> Visit www.survivingsepsis.org
> <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.survivingsepsis.org&data=02%7C01%7Cjoyce.stout%40jefferson.edu%7C528b805b18b944b4b0f308d4ee3d5f83%7C55a89906c710436bbc444c590cb67c4a%7C0%7C0%7C636395394738676905&sdata=BNRiHWdPf2aHVJf%2BgFuw9Vx82%2B%2Fsw00tS5gFBj48220%3D&reserved=0>
>  and www.iculiberation.org
> <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.iculiberation.org&data=02%7C01%7Cjoyce.stout%40jefferson.edu%7C528b805b18b944b4b0f308d4ee3d5f83%7C55a89906c710436bbc444c590cb67c4a%7C0%7C0%7C636395394738676905&sdata=r45ftLfM%2FK8SKcvIiFzqZTIE5juui%2B04mq7nS9VgNQM%3D&reserved=0>
>
>
> *From:* Tom Benzoni [mailto:benzonit at GMAIL.COM <benzonit at GMAIL.COM>]
> *Sent:* Friday, September 1, 2017 10:37 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] The real cost of alarm fatigue - Help Net
> Security
>
> It's a huge issue.
> I get a sepsis alert on (back of the envelope calculation) 25% of ER
> patients. Laceration. Teenager sore throat. Ankle sprain.
> If I'm too fast on the enter key, I get page after page of irrelevant
> orders, prechecked, that I have to cancel.
> This is plain set mathematics: If everyone screens (+) for sepsis, we
> won't miss anyone. Any abnormal vital sends a sepsis alert. Any. One.
> Vital. Sign.
> Each of these alerts takes their toll on my decision capacity.
> There is no reward for precision. The positive predictive value of these
> triggers is unstudied, but it has to be poor.
> We do have EM research showing ~40% increase in ER administration of
> antibiotics for presumed pneumonia with no change in hospital discharge
> rate of pneumonia.
> tom
>
> On Fri, Sep 1, 2017 at 10:23 AM, Grubenhoff, Joe <Joe.Grubenhoff@
> childrenscolorado.org> wrote:
>
> The struggle is real. Sit on any unit's nursing station and watch how
> often alarms go off without anyone (diagnosticians and others) glancing at
> a monitor or heading to a patient room...and it's not just life-sign
> monitoring equipment. It occurs with EHR alerts about meds and other care
> issues. We recently revamped our sepsis alert notification in our ED.
> Initially the trigger was Heart Rate >95%ile for age + fever. Since just
> about every kid with a fever is tachycardic the alert was triggered
> excessively often with very few true positives. So we switched to using
> hypotension. Far fewer false + . Since hypotension is a late finding, this
> change probably means we could miss kids early in their course of septic
> shock. It begs the question - like the article you reference - is it better
> to screen a lot of false positives where "there may be something wrong" or
> run the risk of raising the detection threshold to focus more on "there is
> clearly something wrong." Perhaps avoiding the workload responding to
> high-sensitivity low specificity alerts and, that work could be funneled
> into thinking about who is actually at risk.
>
> jg
>
> BMC Med Inform Decis Mak. 2017 Apr 10;17(1):36. doi:
> 10.1186/s12911-017-0430-8.
>
> Effects of workload, work complexity, and repeated alerts on alert fatigue
> in a clinical decision support system.
>
> Ancker JS1,2,3, Edwards A4,5, Nosal S6,7, Hauser D6, Mauer E4, Kaushal
> R4,5; with the HITEC Investigators.
>
> -----Original Message-----
> From: HM Epstein [mailto:hmepstein at GMAIL.COM]
> Sent: Friday, September 01, 2017 8:18 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: [IMPROVEDX] The real cost of alarm fatigue - Help Net Security
>
> https://www.helpnetsecurity.com/2017/09/01/real-cost-alarm-fatigue/
>
> I was halfway through this article on alarm fatigue and misdiagnosis,
> before I realized it was about cyber attacks on complex computer systems
> and not about doctors and nurses caring for patients in a hospital system.
> Since I'm not a doctor or a nurse, I need to ask those of you who are, is
> this a relevant description of hospitalists' and ED staff's experience with
> alarm fatigue and the resulting risk of misdiagnosis from ignoring a
> trigger event?
>
> Best,
> Helene
>
>
>
>
> Sent from my iPhone
>
>
>
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> <Technologic_Distractions__Part_1____Summary_of.8.pdf>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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