Roundtable No°1 | 2025: Alarm Management - Adverse events and "collateral damage"
Note: The next roundtable will take place on March 13 under the title “Silent innovation: How interoperability is setting new standards in the Silent Patient Room” at the Berlin Simulation and Training Center (BeST). Have we piqued your interest? Then you can register here to take part in person or online!
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On January 23, the first Patient Monitoring Roundtable of the year took place at BIH Digital Labs. The focus was on the topic of patient monitoring and alarm management: adverse events and “collateral damage”. The respected experts Dr. Udo Jendrysiak and Dr. Dirk Hüske-Kraus from BVMI used their many years of experience to help us identify problems and challenges in this area. They demonstrated how practical solutions can be developed to combat alarm fatigue and thus improve patient safety in the long term.
Alarm fatigue and its effects: Insights from the keynote
The event began with a keynote speech that introduced the participants to the complex topic. Factors influencing alarm systems, challenges in monitoring and communicating alarms and the increasingly prevalent problem of alarm fatigue were discussed. The speakers gave practical examples and showed how an overload of alarms can lead to serious consequences.
Sherlock: On the trail of critical alarm causes 🕵🏻♀️
As part of the interactive breakout sessions, participants were invited to take on the role of investigators in order to identify the causes of alarm problems and develop practical solutions. After a systematic analysis, the results from the groups were compiled and discussed.
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A ward with a high alarm load and structural problems that led to desensitization to critical alarms. Red alarms were often ignored as they were considered “normal”. Due to their latching function, they remained active after normalization of the vital parameter and suppressed yellow alarms. Paradoxically, they were therefore sometimes favored as they appeared to reduce the overall number of alarms. Options for improvement included staff awareness, optimized alarm configurations and clear SOPs.
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A patient who was being monitored with telemetry suffered a cardiac arrest without the nursing staff being aware of the alarm. The investigation showed that the alarm forwarding to the patient call system was technically unreliable. Reliable alarm systems and better technical monitoring were identified as the key to the solution.
The concluding discussion emphasized in particular:
The need for structured alarm management to ensure patient safety.
The involvement of interdisciplinary teams to unite technical, nursing and medical perspectives.
The role of data analytics and AI to prioritize clinically relevant alarms and reduce alarm fatigue.
Take-Home Messages
Alarm fatigue is a serious risk: a high number of irrelevant alarms leads to habituation and ignorance of critical alerts
Monitoring must be adapted to criticality: Systems should be configured according to the patient's risk assessment.
Technical systems need clearly defined purposes: Unreliable alarm forwarding without risk management is a threat to patient safety.
Mobile alerting cannot replace missing personnel - but it can reduce risks and increase efficiency.
Interdisciplinary cooperation is the key: nursing, doctors, technology and IT must work together to create sustainable solutions.
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Thanks and outlook 🚀
A big thank you to everyone who contributed to the success of the event with their committed contributions and lively discussions, especially Dr. Udo Jendrysiak and Dr. Dirk Hüske-Kraus from BVMI, who enriched the evening with their expertise and provided decisive impetus.
We would also like to invite you to join us at the next Patient Monitoring Roundtable. This will take place on March 13, 2025 at the Berlin Simulation and Training Center (BeST) and has the exciting title: “Silent innovation: How interoperability is setting new standards in the Silent Patient Room”. Register here - we look forward to your participation!
The Patient Monitoring Roundtable is organized and hosted by INCH e.V. (Initiative for Innovation and Collaboration in Healthcare e.V.) in collaboration with the Institute for Medical Informatics at Charité – University Medicine Berlin.