Friday, January 12, 2018

What if it was Your Loved One in the Bed? The Absence of Alarm Fatigue in our MICU!

Back in July, I wrote a blog about “alarm fatigue.” In that blog I discussed my experience as a pediatric resident in a Neonatal Intensive Care Unit with alarms that constantly went off. We had become oblivious to them, unconsciously assuming that they were false alarms. In that blog I also commented that in highly reliable high-risk systems, like in an airplane cockpit, the alarms are minimized to those that are critical and that in those systems everyone responds immediately to them.

This morning I was on our Lean Daily Management walk in the MICU. Stacey Klingler, RN, the charge nurse, was presenting the Board accompanied by her manager, Rachel Ridgely, RN. Stacey was in mid-sentence explaining something to us when a patient alarm went off. Stacey immediately stopped and started to move to the patient’s room as did Rachel. I turned and looked towards the source of the alarm to see that other staff members were on the move as well. A staff member gave a thumb’s up “all clear” and everyone went back to what they were doing. Without missing a beat, Stacey finished her explanation. I was so proud of Stacey, Rachel and the entire team. If it is your loved one who is a patient in our ICU, you don’t have to worry about an alarm being ignored.

We thanked Stacey and Rachel for exhibiting the “preoccupation with failure” that all high reliability teams exhibit and for not assuming that the alarm was false or would be dealt with by someone else. Afterwards, I reflected on how quiet the unit had seemed before the alarm went off even though the unit was very full. We are making excellent progress in eliminating alarms that are not helpful and in presuming that all alarms are real until proven otherwise.


Rachel also told us that she was meeting with the leaders of our equipment hub. A few years ago we created the hub to remove clutter (and eliminate blocked corridors in the event of a fire) from our patient care units and also to have a system where we always knew where our equipment was. This way it could be moved quickly to where it was needed. At that time, we realized that hard-working, well-intentioned physicians and nurses were hoarding equipment because they were afraid that they would not get it back when they needed it…in other words, they knew that the system for removing equipment from and returning it to the units was unreliable.  Well, our system has worked pretty well since we created it but Rachel was seeing some drift away from our standard work. The physicians and nurses were beginning to hoard things again after one or two episodes where they had called for things that could not be found.

It is not a surprise that workers in unreliable systems begin to work around the system. They are not doing it for malicious reasons. They do it because they believe it will help them get their work done. But, as students of systems, we need to point out that when a system starts to fail and people stop following the design, it actually makes the system worse! Rachel is taking the correct step to meet with the hub leaders and ensure that we continue to follow our standard work to make sure that everything is in its place and moves according to need.

What do you think? Do you see other examples of drift away from standard work? Please comment below.

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