• 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 Irit R Rasooly.
• Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
• J Hosp Med. 2023 Nov 1; 18 (11): 994998994-998.

AbstractAlarm 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.© 2023 Society of Hospital Medicine.

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