FDA releases ventilator alarm safety recommendations

Referencing a recent report published in Nursing2011, the FDA recommended a number of precautions related to audible ventilator alarms—such as familiarizing staff with ventilator features and following established protocols—in a recent safety notification published on its website.

The FDA received more than 2,500 adverse event reports associated with ventilator use in 2010, nearly a third of which were alarm-related. Some of those event reports reflected deteriorating patient conditions, the agency noted, but many indicated preventable malfunctions or human error.

To increase patient safety, the agency is recommending the following precautions:

• Be familiar with the ventilators in your facility; not all ventilators have the same features or safety mechanisms, including alarms.
• Follow your facility’s established protocols to ensure ventilators have the same features or safety mechanisms, including alarms.
• At the beginning of your shift and as clinically indicated, confirm that ventilator settings are correct and clinically appropriate and that alarms are appropriately set.
• Confirm that audible alarms can be heard in the intended environment of use.
• When you hear a ventilator alarm, respond immediately by going to the patient’s bedside.
• If possible, quickly identify the reason for the alarm and intervene appropriately.
• Immediately assess the patient to identify any deterioration in clinical status caused by the alarm situation, such as change in mentation, respiratory distress, decreased SpO2, bradycardia or hypotension.
• If patient compromise is identified, activate the rapid response team and manually ventilate the patient with a manual resuscitation bag. If the patient is unresponsive, apneic, and pulseless, call a code and initiate basic life support.
• Follow your facility’s protocol for reporting ventilator adverse events and near-misses.

 
Click here for the full notice.