Alarm Summit Agenda


Tuesday, October 4, 2011
8:45-9:15 am	Keynote Presentation
	George Blike, MD, Dartmouth-Hitchcock Medical Center
9:15-10:30 am	Defining the Problem: It's More Than A "Nuisance"
	James Blum, MD, University of Michigan Health System Barbara Drew, RN, PhD, FAAN, FAHA, Univeristy of California, San Francisco
	Hundreds of preventable patient deaths in a five-year period are attributed to “alarm fatigue.” It’s easy to say the problem is “too many nuisance alarms.” It’s far more crucial to expand our understanding, to include the multiple facets in a complex system of systems. Panelists will help define the problem from various stakeholder perspectives, followed by a moderated discussion with the audience.
	Session goals:
	Identify all possible perspectives and aspects in defining alarms issues, so that the solution is not driven as simply as “reducing nuisance alarms” Identify patterns and themes underlying the issues Set the stage for the remainder of the event
10:45-Noon	How We Got Here: Regulatory, Liability, and Risk Management Limitations Impacting Medical Device Alarms (Unintended Consequences of a “No Risk Tolerated” World)
	Felipe Aguel, PhD, U.S. Food and Drug Administration James Keller, MS, ECRI Institute Katie McDermott, Morgan, Lewis & Bockius LLP
	Panelists will provide an overview of the medical-legal issues and regulations related to health provider behavior with alarm management; alarm parameters, including how they relate to appropriate specificity and sensitivity settings; and obstacles that must be overcome to spur innovation and reduce “nuisance” alarms. The moderator will engage the audience and panelists in a discussion about experiences with these issues and areas for improvement.
	Session goals are to:
	Identify obstacles to overcome in order to spur innovation of medical device alarms List the issues that must be addressed in order to reduce nuisance alarms while maintaining individual patient safety Identify the medical-legal barriers to behavior change and care improvement Prioritize the urgency of these issues: identify the top 3-5
Noon-1:00 pm	Simulation Testing For Medical Device Alarms
	Richard McNeer, MD, PhD, University of Miami
1:00-2:45 pm	“We Didn’t Hear It:” Optimizing the Environment of Care
	Ilene Busch-Vishniac, PhD, McMaster University Maria Cvach, MS, RN, CCRN, Johns Hopkins Hospital, and Kathryn Pelczarski, ECRI Institute Rebecca Shultz and Elena Simoncini, VA Boston Healthcare System
	Panelists will identify the numerous environmental factors that impact the way clinicians pay attention and respond or “don’t respond to” medical device alarms. Workflow, system management challenges and opportunities, and overall environmental noise also will be addressed. The moderator will then ask the audience to further identify and discuss the issues and set priorities for potential changes that need to be addressed for an optimal culture, human, physical, workflow, and technology integration and interaction in order to improve monitoring systems and the environment of care, and ultimately improve patient safety.
	Session goals:
	Identify the human factors that support or detract from human cognition and attention to alarm signals Learn what contributes to the friction points: workflow, system management, and other environment of care issues, and what would enable change Prioritize the top 3-5 issues that must be addressed
3:00-4:15 pm	Industry Can Help: Alarm Design
	David Barash, MD, GE Healthcare Julian Goldman, MD, Massachusetts General Hospital Michael O’Reilly, MD, Masimo Corporation Michael Wiklund, PE, CHFP, Wiklund Research & Design
	Panelists will address how some alarm problems can be solved by re-design. Problem areas they will discuss include escalated alarms, delayed signals, alarm settings and ease of use, number of severity categories are “how many are enough?,” design trade-offs, and more. The moderator will ask audience members to participate in a discussion of these and other design issues, and what it will take to achieve consensus on potential solutions that could benefit the entire healthcare system.
	Session goals are to:
	Identify ways that alarm design can help solve current problems Identify and if possible gain consensus on issues that might be addressed by standardization
4:15-5:00 pm	Yes, They Matter: Medical Device Alarms Related Standards
	Frank Block, MD Oliver Christ, Prosystem AG David Osborn, Philips Healthcare
	Panelists will provide a brief overview of medical device alarm related standards and discuss reasons these standards have not been fully adopted throughout the healthcare system. The moderator will ask audience members to provide input on the weaknesses of current alarm standards and to identify ways to strengthen them.
	Session goals:
	Identify challenges associated with adopting current standards and ideas on how to overcome them Identify additional standards that may be needed to standardize alarm design and/or related terminology
5:00-5:30 pm	First Day Wrap-up
	The Summit Moderator will review discussions from Day 1, and review the schedule for Day 2. Audience members will have the opportunity to bring up their observations from the day or ask additional questions about the discussions.

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Alarm Summit Agenda

Tuesday, October 4, 2011