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Smart Reasoning:

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Qaagi - Book of Why

Causes

Effects

False positives are commonleadingto alarm fatigue

many false positivesleadsto alarm fatigue

False positives generated from the systemcan resultin alarm fatigue

Caregivers can be overwhelmed by too many alarmsleadingto alarm fatigue

If set conservatively , there will be too many alarmscausingalarm fatigue

too many alarms ( specifically nuisance alarmscan leadto alarm fatigue

Frequent false alarmscausingalarm fatigue

nuisance and false alarms(passive) is caused byAlarm fatigue

False alarms are very commoncan leadto alarm fatigue

false alarms and alerts(passive) caused byAlarm fatigue

many false alarmsresultingin " alarm fatigue

inundate clinicians with false and non - actionable alarmscausealarm fatigue

several factorscontributeto alarm fatigue

a number of factors(passive) is caused byAlarm fatigue

environmental factorscontributeto alarm fatigue

Many factorscontributeto alarm fatigue

The high number of false alarmshas ledto alarm fatigue

thousands of false alarms ... each patient7can leadto alarm fatigue

the lowest rate of false alarmsleadto alarm fatigue

false alarms or artifact signalscontributeto alarm fatigue

With so many alarms per patient per day , it is no surpriseleadsto alarm fatigue

nurses receiving too many alarms without sufficient information(passive) caused bythe alarm fatigue

excessive amount of non - actionable alarms in the fields of mobility , space operations and healthcare(passive) caused byalarm fatigue

a significant number of false alarms ... over timecan leadto alarm fatigue

False alarms and nuisance alarms ... the biggest problemsleadto alarm fatigue

High sensitivity of sensors ... false alarmscausealarm fatigue

false alarms and too many devices generating alarmscontributedto alarm fatigue

auditory cognitive factorscan leadto alarm fatigue

a wide range of factors(passive) is caused byAlarm fatigue

Tags : patient satisfaction , clinical communications , patient experience , HCAHPS , CMS ​The sheer volume of alarms in the typical hospital roomcausesalarm fatigue

A prevalence of false alarms emanating from monitoring systemshas resultedin alarm fatigue

The large number of clinically insignificant and false alarmscan leadto alarm fatigue

types of alarms ... state factorscontributeto alarm fatigue

Conclusions True AVR alarmsmay contributeto alarm fatigue

The volume of false alarms from several patients on a daily basismay leadto alarm fatigue

a device that potentially creates more alarmscould ... preventalarm fatigue

one another2–5 — factorspotentially contributingto alarm fatigue

false alarms and the reluctance of some police forces to respond to unsubstantiated calls(passive) caused byAlarm fatigue

the overuse of patient monitors ... principal factorscausealarm fatigue [ 7,14

aami.org ) Up to 80 % of alarms may be not actionableleadingto alarm fatigue

to sentinel events and deaths of patients ( Cvach , 2012has ledto sentinel events and deaths of patients ( Cvach , 2012

mistakes and harm patients 1 comments Comments are moderated before they are publishedcan causemistakes and harm patients 1 comments Comments are moderated before they are published

in missed patient events and preventable deathshas resultedin missed patient events and preventable deaths

to patient harm or even deathcan leadto patient harm or even death

in desensitization to the alarms , which can lead to missed alarms or a delayed response to alarms.1 Such desensitization to alarmscan resultin desensitization to the alarms , which can lead to missed alarms or a delayed response to alarms.1 Such desensitization to alarms

in them tuning out these notifications and missing the alarms that truly signal a patient ’s critical medical crisiscan resultin them tuning out these notifications and missing the alarms that truly signal a patient ’s critical medical crisis

in hospital deaths April 22resultingin hospital deaths April 22

stress , depression , reduced productivity and burnout among clinician ... making this a challenge that needs addressing [ 3can ... causestress , depression , reduced productivity and burnout among clinician ... making this a challenge that needs addressing [ 3

to medical errors and an unsafe hospital culturecan leadto medical errors and an unsafe hospital culture

a patient ’s injuries or deathhaving causeda patient ’s injuries or death

patient harm in New York hospitalscan causepatient harm in New York hospitals

to deaths in hospitals | Futterman , Sirotkin & Seinfeldcontributingto deaths in hospitals | Futterman , Sirotkin & Seinfeld

to patient safety issuescan leadto patient safety issues

caregiver burnout , medical errors , and even deathcausescaregiver burnout , medical errors , and even death

to reflexive silencing of alarmscan leadto reflexive silencing of alarms

to staff burnout , dissatisfaction and high turnoveris leadingto staff burnout , dissatisfaction and high turnover

IMPROVE PATIENT SAFETY Communication breakdowns(passive) caused byIMPROVE PATIENT SAFETY Communication breakdowns

to major accidents , such as the BP Deepwater Horizon incidenthas ledto major accidents , such as the BP Deepwater Horizon incident

to deaths in hospitals On behalf of Futterman , Sirotkin & Seinfeldcontributingto deaths in hospitals On behalf of Futterman , Sirotkin & Seinfeld

to deaths CHICAGO ( APcan leadto deaths CHICAGO ( AP

in desensitization and even missed alarmsoften resultsin desensitization and even missed alarms

to missed alarms , which is a real problemleadsto missed alarms , which is a real problem

to missed alarms or even desensitizationcan leadto missed alarms or even desensitization

them to ignore or become desensitized to such alerts ( iHealthBeat , 3/26leadsthem to ignore or become desensitized to such alerts ( iHealthBeat , 3/26

to patient injury or deathcan contributeto patient injury or death

to the death of a heart patientcontributedto the death of a heart patient

to longer response times or to missing important incidentscould leadto longer response times or to missing important incidents

an unsafe patient environment because a life - threatening event may be missed in this milieu of sensory overloadcreatesan unsafe patient environment because a life - threatening event may be missed in this milieu of sensory overload

prehospital patient care errorscausingprehospital patient care errors

navigation accidentscausingnavigation accidents

to the death or catastrophic injury of your loved one or you suspect nursing home abuse or neglectledto the death or catastrophic injury of your loved one or you suspect nursing home abuse or neglect

in desensitization , missed alarms , and delayed responsesresultingin desensitization , missed alarms , and delayed responses

at least 11 patient deaths between 2005 and 2011causedat least 11 patient deaths between 2005 and 2011

to an average of two dozen deathshas ledto an average of two dozen deaths

to the patient 's death.(3contributedto the patient 's death.(3

death in hosptialscausingdeath in hosptials

Harrigan ’s deathcausedHarrigan ’s death

to Patient ’s Death | Steinberg , Goodman & KalishContributedto Patient ’s Death | Steinberg , Goodman & Kalish

to a patient ’s death or significant injury to a patientleadsto a patient ’s death or significant injury to a patient

to delayed responses , missed alarms , and patient safety events ( ECRI Institute , 2013leadsto delayed responses , missed alarms , and patient safety events ( ECRI Institute , 2013

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Smart Reasoning:

C&E

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