Anaesthesia monitor alarms: a theory-driven approach

Ergonomics

Volumn 55, Issue 12, 2012, Pages 1487-1501

  Raymer, Karen E ^a,b   Bergström, Johan ^b   Nyce, James M ^b,c  

^a MCMASTER UNIVERSITY   (Canada)

^b LUND UNIVERSITY   (Sweden)

^c BALL STATE UNIVERSITY   (United States)

Author keywords

advanced human machine interfaces; alarms and warnings; anaesthesia alarms; anaesthesia equipment; equipment design; monitoring; patient safety; socio technical systems

Indexed keywords

ALARMS AND WARNINGS; ANAESTHESIA ALARMS; EQUIPMENT DESIGN; HUMAN MACHINE INTERFACE; PATIENT SAFETY; SOCIOTECHNICAL SYSTEMS;

ANESTHESIOLOGY; COGNITIVE SYSTEMS; DESIGN; MONITORING; PHYSIOLOGY;

ALARM SYSTEMS;

ALARM MONITOR; ANESTHESIOLOGY; BIOENGINEERING; EQUIPMENT; EQUIPMENT DESIGN; HUMAN; PATIENT SAFETY; PHYSIOLOGIC MONITORING; REVIEW;

ANESTHESIOLOGY; CLINICAL ALARMS; EQUIPMENT DESIGN; HUMAN ENGINEERING; HUMANS; MONITORING, PHYSIOLOGIC; PATIENT SAFETY;

EID: 84869150822     PISSN: 00140139     EISSN: 13665847     Source Type: Journal    
DOI: 10.1080/00140139.2012.722695     Document Type: Review

References (60)

1. Ansermino, J.M., Dosani, M., Amari, E., Choi, P.T. and Schwartz, S.K.W. 2008. Defining rules for the identification of critical ventilatory events. Canadian Journal of Anesthesia, 55(10): 702-714.
2. Association for the Advancement of Medical Instrumentation (AAMI). A siren call to action. Priority issues from the 2011 medical device alarms summit [online]. Available from: http://www.aami.org/alarms/Materials/2011_Alarms_Summit_ publication.pdf [Accessed 24 February 2012]
3. Baig, M.M, GholamHosseini, H.G., Kouazani, A. and Harrison, M.J. 2011. Anaesthesia monitoring using fuzzy logic. Journal of Clinical Monitoring and Computing, 25: 339-347.
4. Bitan, Y. and Meyer, J. 2007. Self-initiated and respondent actions in a simulated control task. Ergonomics, 50(5): 763-788.
5. Bliss, J.P. and Dunn, M.C. 2000. Behavioural implication of alarm mistrust as a function of task workload. Ergonomics, 43(9): 1283-1300.
6. Bliss, J.P., Gilson, R.D. and Deaton, J.E. 1995. Human probability matching behaviour in response to alarms of varying reliability. Ergonomics, 38: 2300-2312.
7. Bustamante, E.A., Bliss, J.P. and Anderson, B.L. 2007. Effects of varying the threshold of alarm systems and workload on human performance. Ergonomics, 50(7): 1127-1147.
8. Cooper, J.B., Newbower, R.S., Long, C.D. and McPeek, B. 2002. Preventable anesthesia mishaps: a study of human factors. Quality and Safety in Health Care, 11(3): 277-282.
9. Dadashi, N., Wilson, J.R., Golightly, D., Sharples, S. and Clarke, T. 2012. Practical use of work analysis to support rail electrical control rooms: a case of alarm handling. Journal of Rail and Rapid Transit, (In press)
10. Dalal, N.P. and Kasper, G.M. 1994. The design of joint cognitive systems: the effect of cognitive coupling on performance. International Journal of Human-Computer Studies, 40(4): 677-702.
11. Dixon, S.R., Wickens, D. and McCarley, J.S. 2007. On the independence of compliance and reliance: are automation false alarms worse than misses?. Human Factors, 49(4): 564-572.
12. Dorneich, M.D., Ververs, P.M., Mathan, S., Whitlow, S. and Hayes, C.C. 2012. Considering etiquette in the design of an adaptive system. Journal of Cognitive Engineering and Decision Making, 6(2): 243-265.
13. ECRI Institute. 2011. Top 10 Health Technology Hazards for 2012. Health Devices, 40(11): 1-18. Available from: http://www.safeincommon.org//sites/default/files/field_document/health_devices_top_10_hazards_2012.pdf [Accessed 6 September 2012]
14. Edworthy, J. and Hellier, E. 2006. Alarms and human behaviour: implications for medical alarms. British Journal of Anaesthesia, 97: 12-17.
15. Ferris, T.K. and Sarter, N. 2011. Continuously informing vibrotactile displays in support of attention management and multitasking in anesthesiology. Human Factors, 53(6): 600-611.
16. Gorges, M., Markewitz, B.A. and Westenskow, D.R. 2009. Improving alarm performance in the medical intensive care unit using delays and clinical context. Anesthesia & Analgesia, 108: 1546-1552.
17. Graham, K.C. and Cvach, M. 2010. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. American Journal of Critical Care, 19(1): 28-34.
18. Hagenouw, R.R.P.M. 2007. Should we be alarmed by our alarms?. Current Opinion in Anesthesiology, 20: 590-594.
19. Healey, A.N., Sevdalis, N. and Vincent, C.A. 2006. Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics, 49(5-6): 589-604.
20. Heeger, D. 1997. Signal detection theory. Journal of Physiology London, 12(3): 1-10.
21. Heeger, D. 2007. Signal detection theory[online], From New York University. Available from: http://www.cns.nyu.edu/~david/handouts/sdt/sdt.html [Accessed 10 January 2012]
22. Hollnagel, E. and Woods, D.D. 1983. Cognitive systems engineering: new wine in new bottles. International Journal of Man-Machine Studies, 18: 583-600.
23. Imhoff, M. and Kuhls, S. 2006. Alarm Algorithms in critical care monitoring. Anesthesia and Analgesia, 102: 1525-1537.
24. Imhoff, M., Kuhls, S., Gather, U. and Fried, R. 2009. Smart alarms from medical devices in the OR and ICU. Best Practice & Research Clinical Anaesthesiology, 23: 39-50.
25. Kestin, I.G., Miller, B.R. and Lockhard, H. 1988. Auditory alarms during anaesthesia monitoring. Anesthesiology, 69: 106-109.
26. Kiefer, N. and Hoeft, A. 2010. Display of information in the operating room. Current Opinion in Anesthesiology, 23: 772-777.
27. Klein, G., Feltovich, P.J., Bradshaw, J.M. and Woods, D.D. 2005. "Common ground and coordination in joint activity". In Organizational simulation, Edited by: Rouse, W. and Boff, K. 139-184. Hoboken, NJ: John Wiley & Sons.
28. Kowalcyzk, L. 2011. Alarm fatigue blamed in hospital deaths[online] February 13 Available from: http://www.boston.com/lifestyle/health/articles/2011/02/13/patient_alarms_often_unheard_unheeded/?page=full [Accessed 24 February 2012]. From The Boston Globe
29. Masalonis, A. and Parasuraman, R. 2003. Fuzzy signal detection theory: analysis of human and machine performance in air traffic control, and analytic consideration. Ergonomics, 46(11): 1045-1075.
30. McKenna, B.P. and Elm, W.C. 2006. Decision support for the intelligence community: design solutions to real world problems[online] Available from: http://www.resilientcognitivesolutions.com/wordpress/wp-content/uploads/2007/11/solvingcom monproblems-2006.pdf [Accessed 26 May 2012]. From Resilient Cognitive Solutions' website
31. Meyer, J. 2001. Effects of warning validity and proximity on responses to warnings. Human Factors, 43(4): 563-572.
32. Momtahan, K., Hétu, R. and Tansley, B. 1993. Audibility and identification of auditory alarms in the operating room and intensive care unit. Ergonomics, 36(10): 1159-1176.
33. Mondor, T. and Finley, G. 2003. The perceived urgency of auditory warning alarms used in the hospital operating room is inappropriate. Canadian Journal of Anesthesia, 50: 221-228.
34. Niwa, Y. and Hollnagel, E. 2001. Enhancing operator control by adaptive alarm presentation. International Journal of Cognitive Ergonomics, 5(3): 367-384.
35. Nyssen, A.S. and Blavier, A. 2006. Error detection: a study in anaesthesia. Ergonomics, 49(5-6): 517-525.
36. O'Carroll, T.M. 1986. Survey of alarms in an intensive therapy unit. Anaesthesia, 41: 742-744.
37. Ortero, A., Felix, P., Barro, S. and Palicios, F. 2009. Addressing the flaws of current critical alarms: a fuzzy constraint satisfaction approach. Artificial Intelligence in Medicine, 47: 219-238.
38. Parasuraman, R., Hancock, P.A. and Olofinboba, O. 1997. Alarm effectiveness in driver-centered collision-warning systems. Ergonomics, 40: 390-399.
39. Phipps, D.L., Parker, D., Pals, E., Meakin, H., Nsoedo, C. and Beatty, P. 2008. Identifying violation-provoking conditions in a healthcare setting. Ergonomics, 51(11): 1625-1642.
40. Pollack, I. and Maddans, A.B. 1964. On the performance of a combination of detectors. Human Factors, 6: 523-531.
41. Pott, C., Cnossen, F. and Ballast, A. More than psychologists' chitchat: the importance of cognitive modelling for requirements engineering in complex and dynamic environments. Proceedings of SREP'05. August29-302005. pp.163-175. Limerick, Ireland: University of Limerick.
42. Roth, E.M. and Pew, R.W. 2008. Integrating cognitive engineering in the systems engineering process: opportunities, challenges, and emerging approaches. Introduction to the special issue. Journal of Cognitive Engineering and Decision Making, 2(3): 161-164.
43. Sanderson, P.M., Wee, A. and Lacherez, P. 2006. Learnability and discriminability of melodic medical equipment alarms. Anaesthesia, 61: 142-147.
44. Schmid, F., Goepfert, M.S., Kuhnt, D., Eichhorn, V., Diedrichs, S., Reichenspurner, H., Goetz, A.E. and Reuter, D.A. 2011. The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery. Anesthesia and Analgesia, 112(1): 78-83.
45. Seagull, F.J. and Sanderson, P.M. 2001. Anesthesia alarms in context: an observational study. Human Factors, 43: 66-78.
46. Siebig, S., Kuhls, S., Imhoff, M., Gather, U., Scholmerich, J. and Wrede, C.E. 2010. Intensive care unit alarms: how many do we need?. Critical Care Medicine, 38: 451-456.
47. Smith, A.F., Goodwin, D., Mort, M. and Pope, C. 2003. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. British Journal of Anaesthesia, 91: 319-328.
48. Sorkin, R.D. and Woods, D.D. 1985. Systems with human monitors: a signal detection analysis. Human-Computer Interaction, 1: 49-75.
49. Solet, J.M. and Barach, P.R. 2012. Managing alarm fatigue in cardiac care. Progress in Pediatric Cardiology, 33: 85-90.
50. nd ACM SIGHIT International Health Informatics Symposium. January28-302012. pp.533-542. Miami, FL. New York, NY: ACM.
51. Stoelting, R.K. and Miller, R.D. 2006. Basics of anesthesia, New York, NY: Churchill Livingstone.
52. Takla, G., Petre, J.H. and Doyle, D.J. 2006. The problem of artefacts in patient monitor data during surgery: a clinical and methodological review. Anesthesia and Analgesia, 103: 1196-1204.
53. Watson, M. and Sanderson, P. Work domain analysis for the evaluation of human interaction wtih anesthesia alarm systems. Proceedings of the 1998 Australasian computer human interaction conference. pp.228-235. Los Alamitos, CA: IEEE Computer Society.
54. Wee, A.N. and Sanderson, P.M. 2008. Are melodic medical equipment alarms easily learned?. Anesthesia and Analgesia, 106: 501-508.
55. Weil, K.M. 2009. Alarming monitor problems[online] September 18 Available from: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm222022.htm [Accessed 24 February 2012]. From The Food and Drug Administration
56. Whittingham, R.B. 2004. The blame machine: why human error causes accidents, Burlington, MA: Elsevier.
57. Woods, D.D. 1985. The alarm problem and directed attention in dynamic fault management. Ergonomics, 38(11): 2371-2393.
58. Woods, D.D., Patterson, E.S. and Roth, E.M. 2002. Can we ever escape from data overload? A cognitive systems diagnosis. Cognition, Technology & Work, 14: 22-36.
59. Wright, M.C., Dawodu, M., Segall, N., Taekman, J.M. and Mark, J.B. 2011. Anesthesia crisis alerting: a qualitative study toward understanding the complexity of crisis identification. Anesthesiology, A741
60. Xu, X., Wickens, C. and Rantanen, E.M. 2007. Effects of conflict alerting system reliability and task difficulty on pilots' conflict detection with cockpit display of traffic information. Ergonomics, 50(1): 112-130.