Evidence map›Paper›PMID 37811956›Full record

ArticleJournal of hospital medicine2023

Observing sources of system resilience using in situ alarm simulations.

Melissa McLoone, Meghan McNamara, Megan A Jennings, Hannah R Stinson, Brooke T Luo, Daria Ferro, Kimberly Albanowski, Halley Ruppel, James Won, Christopher P Bonafide and 1 more

Open access · greenAbstract read
In one paragraph

Article in Journal of hospital medicine, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
0.3field-weighted citation impact, top 37% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed, 1 citations in OpenAlex.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

11 authors at 1 institution in 1 country.

Melissa McLooneDepartment of Nursing, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.ORCID 0009-0006-0322-8918
Meghan McNamaraDepartment of Nursing, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Megan A JenningsDepartment of Nursing, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Hannah R StinsonDepartment of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Brooke T LuoSection of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Daria FerroSection of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Kimberly AlbanowskiSection of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.ORCID 0009-0009-6435-5314
Halley RuppelSchool of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
James WonCenter for Healthcare Quality & Analytics (CHQA), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Christopher P BonafideSection of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.ORCID 0000-0003-2823-5883
Irit R RasoolySection of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.ORCID 0000-0002-1368-534X
Children's Hospital of Philadelphia · US

Funding

Pediatric patient safety learning laboratory to re-engineer continuous physiologic monitoring systemsR18HS026620 · AHRQ · CHILDREN'S HOSP OF PHILADELPHIA · PI BONAFIDE, CHRISTOPHER PETER · 2018 to 2021
$2.4M
Averting Diagnostic Error Through Improved Recognition of Child AbuseK08HS028682 · AHRQ · CHILDREN'S HOSP OF PHILADELPHIA · PI RASOOLY, IRIT R · 2022 to 2024
$429k
AHRQ HHS K08 HS028682AHRQ HHS R18 HS026620
6 · The paper itself

Abstract

Alarm fatigue (and resultant alarm nonresponse) threatens the safety of hospitalized patients. Historically threats to patient safety, including alarm fatigue, have been evaluated using a Safety I perspective analyzing rare events such as failure to respond to patients' critical alarms. Safety II approaches call for learning from the everyday adaptations clinicians make to keep patients safe. To identify such sources of resilience in alarm systems, we conducted 59 in situ simulations of a critical hypoxemic-event alarm in medical/surgical and intensive care units at a tertiary care pediatric hospital between December 2019 and May 2022. Response timing, observations of the environment, and postsimulation debrief interviews were captured. Four primary means of successful alarm responses were mapped to domains of Systems Engineering Initiative for Patient Safety framework to inform alarm system design and improvement.

Indexed as

Clinical AlarmsChildEquipment FailureHumansIntensive Care UnitsMonitoring, PhysiologicPatient Safety

Identifiers

PMID37811956
PMCPMC10841417
OpenAlexW4387440949

What OpenQuestion holds

Textmetadata
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.