On Alert

Lessons Learned

On alert

Shands addresses systemwide problem with alarms after event in NICU

by April Frawley Birdwell

The SituationA baby on extracorporeal membrane oxygenation, or ECMO, in the neonatal intensive care unit was receiving the drug heparin, standard protocol to prevent blood clotting. A staff member incorrectly entered the dose of the anticoagulant into the pump by mistake and bypassed high-dose alerts from the machine. Several hours later, it was discovered that the baby had received too much heparin, which can result in excessive bleeding. Fortunately, tests showed the baby was not affected by the increased dose.


The ResponseStaff members and leaders quickly took action to find out what led to the error and prevent something similar from happening in the future. Clinical risk management leaders assembled a multidisciplinary team to conduct what is known as a root-cause analysis. A root-cause analysis helps get to the true cause of the issue and uncover whether there are system wide processes that need to be changed.


The DiscoveryBy working with the employee involved and other staff members on the unit, the team discovered that the low-dose and high-dose alarms on the machines sounded similar and that staff had become  accustomed to manually bypassing low-dose alarms. “(The heparin low-dose parameter) was set at a level that it frequently alarmed. They were accustomed to overriding it,” said Susan Keating, director of  clinical risk management for Shands at UF. “As human beings, we get alarm fatigue.” Further investigation revealed that by simply lowering the lowdose parameters on the pump, 88 percent of nuisance alarms were eliminated.


The OutcomeThe event occurred just as Shands at UF had begun to learn about the principles of “Just Culture,” which acknowledges that even  the most skilled employees make human mistakes. “In Just Culture, you look at the intent, not the outcome,” Keating said. “When people make human errors, you console the employee and fix the system.” (For more information on Just Culture). The team  focused on fixing the real problem — the alarm settings on the pumps. The pump’s heparin dosing parameters were revised to  reduce unnecessary low-dose alarms and prevent overdose by creating a hard stop for heparin infusions over a certain dosing limit.  They also implemented a new system for alarm double-checks and evaluated and adjusted heparin protocol for ECMO  patients.