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Publication Type: Safer Practice Notice
Single or Multiple Incident: Multiple
Date: 2/11/2016 12:00:00 AM
Country: Canada
Organization: Alberta Health Services
This notice addresses the patient harm that can occur when pulse oximetry audible alarms and heart rate tones are turned down or silenced. Silencing the auditory alarms has led to delays in recognizing and responding to patients with compromised cardiovascular, respiratory and neurological reserves. Flashing visual indicators on pulse oximetry devices do not provide adequate queues to detect compromised patients. The alert provides direction to prevent related incidents.

Additional Details

Device:
pulse oximetry alarms
Medication/Gas/Fluid:
procedural sedation medications
Medication/IV List:
anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine)

Rules / Policies / Procedures
  1. To ensure timely reaction to changes in patient status do not rely solely on visual pulse oximetry indicators.
  2. To ensure timely reaction to changes in patient status do not silence the heart rate tones or audible alarms on pulse oximetry devices.
Training
  1. Consult with your local Clinical Educator and Clinical Engineering Department to discuss the best configuration of auditory and visual alarms for your procedure room and to ensure an audible heart rate tone is set.

Potential for patient harm when silencing pulse oximetry alarms or tones during procedures requiring sedation