Organizational-historical analysis of the "failure to respond to alarm" problems

IEEE Transactions on Systems, Man, and Cybernetics Part A:Systems and Humans.

Volumn 34, Issue 6, 2004, Pages 772-778

  Xiao, Yan ^a   Seagull, F Jacob ^a   Nieves Khouw, Fe ^a   Barczak, Nancy ^a   Perkins, Sherry ^a  

^a UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ALARM SYSTEMS; HUMAN ENGINEERING; INTENSIVE CARE UNITS; PERSONNEL; SOCIETIES AND INSTITUTIONS;

ACCIDENT INVESTIGATION; HEALTHCARE SYSTEMS; HUMAN ERRORS; SYSTEMS APPROACH;

HEALTH CARE;

EID: 7444238313     PISSN: 10834427     EISSN: None     Source Type: Journal    
DOI: 10.1109/TSMCA.2004.836781     Document Type: Article

References (17)

1. J. P. Bliss, R. D. Gilson, and J. E. Deaton, "Human probability matching behavior in response to alarms of varying reliability," Ergonomics, vol. 38, no. 1, pp. 2300-2313, 1995.
2. R. I. Cook, M. Render, and D. D. Woods, "Gaps in the continuity of care and progress on patient safety," Brit. Med. J., vol. 320, pp. 791-794, 2000.
3. (2003) Alarms, Unnoticed or Unheeded. ECRI Report. ECRI (2001). [Online]. Available: http://www.ecri.org
4. "Critical alarms and patient safety: ECRI's guide to developing effective alarm strategies and responding to JCAHO's alarm-safety goal," Health Devices, vol. 31, no. 11, pp. 3970-417, 2002.
5. J. C. Flanagan, "The critical incident technique," Psycholog. Bull., vol. 51, pp. 327-358, 1954.
6. B. Frey et al., "Comprehensive critical incident monitoring in a neonatalpediatric intensive care unit: Experience with the system approach" Intensive Care Med., vol. 26, no. 1, pp. 69-74, 2000.
7. I. G. Kestin, B. R. Miller, and C. H. Lockhart, "Auditory alarms during anesthesia monitoring," Anesthesiology, vol. 69, pp. 106-109, 1988.
8. L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, Eds., To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 2000.
9. J. Meyer and Y. Bitan, "Why better operators receive worse warnings," Human Factors, vol. 44, pp. 343-354, 2002.
10. J. Reason, Human Error. Cambridge, U.K.: Cambridge University Press, 1990.
11. F. J. Seagull and P. M. Sanderson, "Anesthesia alarms in context: An observational study," Human Factors, vol. 43, pp. 66-78, 2001.
12. R. D. Sorkin, "Why are people turning off our alarms?," J. Acoustic Soc. Amer., vol. 84, no. 3, pp. 1107-8, 1988.
13. J. H. Tinker, D. L. Dull, R. A. Caplan, R. J. Ward, and F. W. Cheney, "The role of monitoring devices in prevention of anesthetic mishaps: A closed claims analysis," Anesthesiology, vol. 71, no. 4, pp. 541-546, 1989.
14. D. D. Woods, "The alarm problem and directed attention in dynamic fault management," Ergonomics, vol. 38, no. 11, pp. 2371-2393, 1995.
15. Y. Xiao, C. F. Mackenzie, F. J. Seagull, and M. Jaberi, "Managing the monitors: An analysis of alarm silencing activities during an anesthetic procedure," in Proc. IEA 2000/HFES 2000 Congr., vol. 4, 2000, pp. 250-253.
16. Y. Xiao and F. J. Seagull, "An analysis of problems with auditory alarms: Defining the roles of alarms in process monitoring tasks," in Proc. Human Factors Ergon. 43rd Annu. Meeting, 1999, pp. 256-260.
17. Y. Xiao, F. J. Seagull, "Toward a user friendly health care environment: The case of alarms," Forum (Risk Manage. Found., Harvard Med. Inst. ), vol. 21, no. 2, pp. 17-18, 2001.