Alarm Fatigue

I remember being a Pediatrics resident in a Neonatal Intensive Care Unit during my training and hearing many alarms going off simultaneously. Team members were frequently slow to respond to the alarms or they just didn’t respond at all. This was because they went off all the time and it was usually because the leads had become disconnected from the baby or the alarm was set to go off for something that we knew was not really an emergency…. like a momentary high heart rate because the baby was crying.  This concept, not reacting to an alarm because we have learned that they go off for reasons that do not require immediate action, has been termed alarm fatigue. Can you imagine being on a commercial jet where the pilot and the co-pilot were suffering from alarm fatigue?

“False” alarms breed contempt for the alarm system and teach people to ignore the alarm.  Do you always leave a building as soon as you hear a fire alarm? Probably not, because you have witnessed fire alarms going off when there was no fire. If this is the case, you have begun to assume that the alarm is false and the alarm is no longer serving its intended purpose. At GBMC, our standard work is to announce the testing of a fire alarm before we test so as to not create alarm fatigue and put our people at risk.

When I was a Pediatrics resident I received no training in complex systems, human factors or the Swiss Cheese Model of error. I did not know about the high-reliability concept of preoccupation with failure. No one taught me to be aware of the so-called “weak signals” that a catastrophe was brewing. No doctor or nurse told me that if I ignored cardiac monitors long enough eventually some baby might get hurt. Today, I know better but only because I have been involved in some cases and have read about many others where smart, well-trained and incredibly hard working clinicians got caught in the trap of alarm fatigue. Allowing devices on a hospital unit to alarm and ignoring the alarms is a hole in the Swiss cheese that is just waiting for a sick patient and hardworking and smart but human staff members to create a real problem.

So, I am asking all of my GBMC colleagues to not ignore alarms. If you hear an alarm respond to it. If the device is defective, then work with your manager to get it fixed or replaced. If devices are alarming because we don’t have good standard work (e.g. the leads are off the patient because they’ve gone for a test, but no one has shut off the device) then create the standard work. If devices are alarming because we have set the device to alarm at too low or too high a rate…reset the device.  If alarms are going off frequently for no good reason, we have to reduce the number of times this occurs.

I know how hard everyone works in our health care system. We should also want to reduce the number of alarms to reduce the stress on us and our patients as well.

Thanks for everyone’s help on this. Please tell me what you think.

New Executive Vice President for Medical Affairs and Chief Medical Officer
Congratulations to Harold Tucker, M.D. who was recently appointed as GBMC’s Executive Vice President for Medical Affairs and Chief Medical Officer. He is replacing the retired John Saunders, M.D. Dr. Tucker has been an active member of the GBMC's medical staff since 1984 and in that time has taken on several important roles. He was the Chief of the Medical Staff for six years and did an outstanding job of advocating for physicians and advanced practitioners and helping to improve patient care. Dr. Tucker will also continue to serve as the President of Greater Baltimore Medical Associates. Please join me in congratulating him as he takes on this important position.

Summertime Fun and a Celebration of Our People

Yesterday, we held our annual employee and volunteer BBQ, titled Camp GBMC HealthCare. This event was a great opportunity for all of the GBMC family to come together and celebrate what we have accomplished, while also having some fun! It is no secret that healthcare requires self-sacrifice and dedication and that the work is truly hard. We spend so much time working to achieve our vision, to provide the care to every patient, every time that we would want for our own loved ones, that at times we need to take a step back, reflect and celebrate what we have achieved, together as the GBMC team!

Everyone seemed to enjoy the music, the good food, camp-themed games, and having a relaxing time with friends and colleagues. I also noticed that there were several magnificent karaoke performers! Many enjoyed participating in or watching tug-of-war, Bingo, and the three-legged, potato sack, and egg and spoon races. It was a great opportunity to celebrate together and leave our work behind, even if only for an hour or so.

Our Philanthropy Team, led by Jenny Coldiron, our Human Resources Team, led by Anna-Maria Palmer, and our Marketing and Communications Team, led by Greg Shaffer, put on a fabulous BBQ! Special thanks to Kim Davenport from Marketing and Shannon Baumler from Philanthropy for their hard work on this event, beginning early in the morning and stretching all the way through the night shift. Lunches were delivered to offsite GBMA practices and Gilchrist homecare staff were given food coupons that they could use at their convenience. At 11 a.m., the barbecue began. Hamburgers, hot dogs, veggie burgers, BBQ chicken, watermelon, salads, and s'mores pops were served by Rouge Catering. The Kona Ice truck was on site providing shaved ice for a cool treat. We assembled again from 10 p.m. until midnight to BBQ and do some karaoke with the night shift staff.

This year, we hosted a fundraising tent called “Camp Hope,” where different departments hosted fundraising activities to benefit our Oncology program. The winners are announced in this week’s Pulse.

We also hosted a horse decorating contest, in which departments decorated papier-mâché horses to show support for Legacy Chase and the Oncology department. A huge thank you to all the departments, units, and practices who participated in the Camp Hope Legacy Chase Horse Decorating Contest! There were 34 horses submitted, and BBQ attendees voted on their favorites! Here are the winners in each category, pictured below clockwise: 

Legacy Chase Theme – Epic Team

Cancer Awareness Theme WINNER  – Oncology Clinical Trials

Cancer Awareness Theme RUNNER UP – (There were so many submissions and a close number of votes) – Inpatient Rehabilitation

Overall Theme – Oncology Support Services

All winners will receive a pizza party celebration.  Please contact Kim Davenport at kdavenport@gbmc.org to schedule.

All in all, we had a great day celebrating our employees! Check out the photos.

What do you think?

Spirit

I have had the good fortune of being away this week with my family. I have enjoyed seeing extended family members, celebrating Independence day and having fun. But everyone knows that the email does not stop coming.

I am very lucky to be the President of GBMC because the positive news hugely outweighs the negative. Among the messages I received this week was one from a GBMC colleague who had been admitted to the hospital after a holiday visit to her patient centered medical home. She was effusive in her praise of those who had served her.

Among the other messages was the notice that next week, July 9-15, is GBMC Spirit Week. This got me wondering about spirit. My first reaction was just how wonderful our marketing, human resources and philanthropy groups are. They are clever and tireless in their efforts to make the hard work of patient care and its associated tasks more rewarding and at times actually fun. I was then wondering which socks I would wear for ‘Crazy Sock Day’. (I don’t think that many who know me would be surprised by this. It is amazing how many comments I get at work if I am not wearing a dark suit, white shirt and a tie.) I also thought about karaoke at the barbecue this Wednesday….

But then my thoughts returned to my GBMC colleague who had been admitted to the hospital for July 4th. Her story awakened me to what spirit really is. Spirit is a rallying cry. It is what joins us together in our mission. Outside of work we have so many differences in our daily lives. But in the hospital, our physician offices or in a Gilchrist setting we are one Team. Teams are all imperfect because they are made up of humans who are imperfect. But spirit brings us together and makes us stronger together. Spirit helps us rejoice in our inherent differences and helps us see them as assets to make the Team richer and better. Spirit helps us look out for each other, celebrate together in good times and console each other and be resilient together in bad times.

So as I return to work I want to wish each and every one of my GBMC colleagues a Happy Spirit Week!