The following scenario is derived from incidents reported to CHPSO:
A stable, ventilator-dependent patient (KP) was placed in a room across from the nurses’ station. The nurse caring for this patient then received a post-operative patient whose condition was deteriorating. A code was called for the post-op patient and several staff in the area responded to assist. During this emergency, KP’s ventilator tubing had become disconnected and the ventilator starting alarming. However, no one responded to the alarm until a custodian passing by approached the nurses’ station and notified the unit clerk that he had noticed an alarm coming from KP’s room for several minutes and wanted to make sure someone was notified. At this point, the clinical staff realized that KP was quickly deteriorating and immediately responded. Unfortunately, they could not resuscitate KP.
Diffuse responsibility is a recognized safety concern in clinical alarm management. In order to manage the large amount of noise in busy and monitored environments, clinicians often “tune out” alarms that are not related to their own patient assignment. There is an underlying assumption that someone else is responding to an alarm associated with another clinician’s patient. Personnel in the area who are not clinicians are intimidated by alarms and assume that a clinician will respond. One approach to solving this issue is to implement the “No Pass Zone.”