Why Bed Alarms Fail To Reduce Patient Falls
Patient falls in healthcare settings has long been a problem that despite many attempts to solve still continues to happen all too frequently. The solution most hospitals and long term care facililities have implemented in recent years are bed and chair alarms. These alarms which are made of weight sensors embedded into a flexible pad, can be placed on a bed, chair or toilet. When the patient’s body breaks contact with the sensor, a noise alarm alerts the nurse which then triggers the nurse to check on the patient. On the face of it, this solutions sounds simply perfect. What could possilby go wrong? Well, it appears that often times this patient fall alert system fails.
A recent study, Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial, investigated whether increasing the usage of bed alarms decreases hospital falls and related events. The study had two different groups. In one group the nurses were given educational materials and training on how to use the bed alarms. The group also had technical support personnel who promoted the use of the alarms and helped with setting them up and troubleshooting problems. In the second group bed alarms were provided but their use was not formally promoted and no support personnel were provided.
As one would expect, the one group in which bed alarm use was encouraged has a usage level nearly 36x higher than the other group. However, the increase in usage DID NOT translate into a decrease in the overall fall rate or number of falls or fall-related injuries. How could this be? The authors provided a couple reasons. One, that the bed alarms were ineffective in decreasing the fall rate because the alarms had a high percentage of false alarms. The false alarms caused the nurses to ignore the warnings in most instances. The authors suggested another other problem with the patient fall alert alarm system—that is by the time the alarm sounds the patient may have already fallen (so much for prevention!)
It is this author’s opinion that the bed alarm device and the system in which it is utilized failed to include human factors/ergonomics in its design. The human-device interaction is poor. It suffers from the “boy who called wolf too many times syndrome”. Humans can be conditioned to ignore alarms if they produce several false alarms. The designers (manufacturers) of these alarms have failed to produce a device that is consistently accurate. That being said, what good is an alarm if it fails to prevent the very thing it was manufactured to solve, i.e. patient falls. Perhaps the first question that should have been asked regarding the system design for preventing patient falls, “Is an alarm device that goes off after the weight is no longer on the surface worth while pursuing?” This would be like a horse owner who has an alarm on the barn door that goes off after the door is wide open. How effective is that? Do you think that would reduce the rate of horse escapes? Not likely.
The results of this study did not surprise me as the design of the system and the design of the device were bound to fail, i.e. result in no decrease in patient falls. Healthcare facilities should take a fresh look at designing a system and a device that is proactive—one that actually focuses on preventing falls instead of one that alerts to falls after the fact. This is a lesson that other industries can benefit from and use to address similar organizational problems that they are currently trying to reduce after-the-fact instead of focusing on preventing it from happening in the first place.