DNP 805 Module 6 Safety Event Analysis Example

Four Minutes Unanswered: A Root Cause Analysis and Action Plan After a Missed Monitor Alarm

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 805: Organizational and Systems Leadership

Instructor Name

Month Day, Year

Four Minutes Unanswered: A Root Cause Analysis and Action Plan After a Missed Monitor Alarm

After harm, the instinct in many organizations is to find out who erred. That approach rarely prevents the next event, because the conditions that produced the mistake remain. This paper analyzes a composite event in a health system's telemetry unit, a cardiac arrest after a sustained ventricular rhythm alarm went unanswered for four minutes, using the RCA² approach, which the National Patient Safety Foundation developed to make root cause analyses produce stronger actions. It presents the event, the timeline, the causal statements, the actions ranked by strength, and how the team will judge whether the actions succeeded.

The Event

A 71-year-old man admitted with heart failure was on remote telemetry monitoring on a 32-bed medical unit. At 3:12 a.m., the central monitoring station registered a sustained ventricular tachycardia alarm. The alarm sounded at the central station and on the assigned nurse's phone. The monitor technician, watching 48 patients across two units, was addressing two other alarms. The assigned nurse was in an isolation room with another patient and did not look at the phone. At 3:16 a.m., the patient could not be roused when a nursing assistant came in to check vital signs. A rapid response and code were called, and the patient was resuscitated but suffered an anoxic brain injury. The event was reported, the family was informed, and a review team was convened within 72 hours.

The Method

The RCA² guidance emphasizes several changes from traditional root cause analysis. Reviews are conducted promptly by a team that includes front-line staff and someone with patient safety expertise, but not people directly involved in the event, who are interviewed instead. The team builds a detailed timeline, identifies contributing factors, writes causal statements that link a cause to an effect and to the event, and then chooses actions using an action hierarchy that ranks interventions from stronger, such as forcing functions and standardized equipment, through intermediate, such as checklists and redundancy, to weaker, such as training and new policies. Each action has a responsible person, a completion date and a measure (National Patient Safety Foundation, 2015).

For this event, the team included a telemetry nurse and a monitor technician from another hospital in the system, a clinical engineer, a cardiologist, a patient safety specialist and a nurse leader who facilitated. The nurse, technician and nursing assistant involved were interviewed separately and offered support through the system's peer support program.

Contributing Factors

The team's interviews and data review identified several contributing factors. Alarm burden was high: in the preceding week, the unit's monitors generated an average of 212 alarms per patient per day, most of them brief or technical. Staff described the phone alerts as constant and rarely actionable. That experience is consistent with research: in a study of consecutive intensive care patients, more than 2.5 million alarms occurred in 31 days, and 88.8% of annotated arrhythmia alarms were false positives, caused by factors including inappropriate alarm settings, poor signal quality and algorithm limitations (Drew et al., 2014). When most alarms are false, clinicians learn to discount them, a phenomenon called alarm fatigue that nursing researchers have described as a serious threat to patient safety, made worse by too many alarms, desensitization and missed true events (Sendelbach & Funk, 2013).

Other factors included the technician's workload of 48 patients, the absence of an escalation rule when an alarm is not acknowledged, the nurse's phone treating a life-threatening alarm the same as a low-priority one, and electrode pads that had not been changed for three days, which contributed to noisy signals and false alarms.

Causal Statements

Causal statements make the logic explicit. First, a high burden of nonactionable alarms, driven by default settings and unchanged electrodes, led staff to discount alarm notifications, which increased the likelihood that the ventricular tachycardia alarm would not receive an immediate response. Second, the absence of automatic escalation when a critical alarm is not acknowledged meant that the alarm remained with a nurse who was unavailable, which delayed recognition by four minutes. Third, a technician workload of 48 patients during a period of multiple simultaneous alarms reduced the technician's ability to call for help, which removed a redundant safeguard.

Actions Ranked by Strength

The team selected actions across the hierarchy, with emphasis on stronger ones. Stronger actions include configuring the alarm system so that unacknowledged critical arrhythmia alarms escalate automatically after 30 seconds to the charge nurse and a second nurse, and after 60 seconds to an overhead page; and giving life-threatening alarms a distinct tone that cannot be silenced from the phone without acknowledgment. Intermediate actions include revised default alarm limits for the unit, developed with cardiology and approved by the medical staff; daily electrode changes built into the morning routine with a checklist; and a limit of 36 patients per technician, with a backup technician on call. Weaker actions, still included, are education on alarm management and a policy defining acknowledgment and response times.

The review also examined whether the event reflected individual failure. It found that the nurse and technician acted as the system had trained them to act in a high-alarm environment, and no disciplinary action was taken.

Measures and Follow-Up

Each action has an owner and a date. Measures include the daily alarm count per patient, the share of critical alarms acknowledged within 60 seconds, the number of escalations to the overhead page, and staff perception of alarm burden on a quarterly survey. The chief nursing officer reports progress to the system's patient safety committee monthly for six months, and the changes will be spread to the system's other telemetry units if results are favorable. The family receives an explanation of what was found and what the system is changing.

Conclusion

A four-minute delay in answering a critical alarm was not the failure of one nurse or technician but the product of alarm burden, missing escalation and workload. RCA² guided the review toward causal statements about systems and toward stronger actions, such as automatic escalation and distinct critical alarms, rather than relying on retraining. Measuring whether the actions change alarm response, and sharing the results with staff and the family, completes the analysis.

References

Drew, B. J., Harris, P., Zègre-Hemsey, J. K., Mammone, T., Schindler, D., Salas-Boni, R., Bai, Y., Tinoco, A., Ding, Q., & Hu, X. (2014). Insights into the problem of alarm fatigue with physiologic monitor devices: A comprehensive observational study of consecutive intensive care unit patients. PLOS ONE, 9(10), Article e110274. https://doi.org/10.1371/journal.pone.0110274

National Patient Safety Foundation. (2015). RCA²: Improving root cause analyses and actions to prevent harm. Institute for Healthcare Improvement. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm

Sendelbach, S., & Funk, M. (2013). Alarm fatigue: A patient safety concern. AACN Advanced Critical Care, 24(4), 378-386. https://doi.org/10.4037/NCI.0b013e3182a903f9