Qualitative Research Critique! Please use article – False Alarms and Overmonitoring : Major Factors in Alarm Fatigue Among Labor Nurses  – ATTACHED BELOW!! Prompt: Use the article provided. Start by f

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Qualitative Research Critique!

Please use article –

False Alarms and Overmonitoring

: Major Factors in Alarm Fatigue Among Labor Nurses  – ATTACHED BELOW!!


Use the article provided. Start by filling out the provided worksheet. Then, using the worksheet as your guide, write a critique to dig deeper into each section and identify the specific examples of each element (e.g., what is the research question? Does the author justify the importance of the research? In the case of a literature review, has the author examined the relevant literature?). Elaborate on each section and evaluate it for its strengths and limitations. Be sure to identify your chosen article and address the following critical elements:



Purpose and Research Question:

What is the research question? Does the author justify the importance of the research? o


Whatdesignandmethodswereused?Aretheyrigorousandsystematic? o

Validity and Reliability:

Is the study valid and reliable? (For qualitative research, this section of your critique should consider the study’s

trustworthiness and rigor.) o

Findings and Conclusions:

Are the conclusions reasonable given the findings?


: What are the strengths and weaknesses of the research article? Do you agree with the author’s conclusions? Why or why not? Did the author succeed or fail in the purpose of the study? Recommend areas for improvement or suggest direction for future research.

Guidelines for Submission:

Your paper must be submitted as a 1–2 page Microsoft Word document with double spacing, 12-point Times New Roman font, one- inch margins, and in APA format.

Qualitative Research Critique! Please use article – False Alarms and Overmonitoring : Major Factors in Alarm Fatigue Among Labor Nurses  – ATTACHED BELOW!! Prompt: Use the article provided. Start by f
False Alarms and Overmonitoring Major Factors in Alarm Fatigue Among Labor Nurses Kathleen Rice Simpson, PhD, RNC, CNS-BC, FAAN; Audrey Lyndon, PhD, RNC, FAAN ABSTRACT Background:Nurses can be exposed to hundreds of alarms during their shift, contributing to alarm fatigue. Purpose:The purposes were to explore similarities and differences in perceptions of clinical alarms by labor nurses caring for generally healthy women compared with perceptions of adult intensive care unit (ICU) and neonatal ICU nurses caring for critically ill patients and to seek nurses’ suggestions for potential improvements. Methods:Nurses were asked via focus groups about the utility of clinical alarms from medical devices. Results:There was consensus that false alarms and too many devices generating alarms contributed to alarm fatigue, and most alarms lacked clinical relevance. Nurses identified certain types of alarms that they responded to immediately, but the vast majority of the alarms did not contribute to their clinical assessment or planned nursing care. Conclusions:Monitoring only those patients who need it and only those physiologic values that are war- ranted, based on patient condition, may decrease alarm burden. Key words:alarm fatigue, clinical alarms, electronic fetal monitoring, labor nurses, nurses, physiologic monitoring alarms M edical devices that generate clinical alerts and alarms are ubiquitous in the hospital setting. Caregivers can be exposed to hundreds of alarms over the course of their shift. 1,2 As physiologic monitoring has become more com- mon, the technology is no longer limited to perioperative and intensive care units (ICUs). General nursing units have multiple electronic devices to routinely track patient vital signs and other physiologic data. Alarm fatigue in the ICU setting has been well studied. 3-9 There is growing evidence that nurses perceive many clinical alerts and alarms as a nuisance, especially those that are inaccurate or nonactionable. 3-6 Over time, false alarms and the constant visual and audi- ble notifications associated with nonactionable alarms can have a negative impact on nurses’ Author Affiliations:Mercy Hospital St Louis, Missouri (Dr Simpson); and Department of Family Health Care Nursing, UCSF School of Nursing, San Francisco, California (Dr Lyndon). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence:Kathleen Rice Simpson, PhD, RNC, CNS-BC, FAAN, Mercy Hospital St. Louis, 7140 Pershing Ave, St. Louis, MO 63130 ([email protected]). Accepted for publication: March 8, 2018 Published ahead of print: June 8, 2018 DOI: 10.1097/NCQ.0000000000000335 response time, nurses’ trust of the clinical alarm system, and patient safety. 3,4,6-9 Patients in the ICU can be assumed to have an illness or condition that requires constant moni- toring. ICU nurses are attuned to caring for crit- ically ill patients whose physiologic parameter changes may offer early warning of patient dete- rioration. In contrast, labor nurses care for gen- erally healthy women who are experiencing a normal life event, yet women in labor are be- ing exposed to an increasing number of moni- tors and their associated clinical alarm systems. 10 Continuous electronic fetal monitoring (EFM), maternal vital sign monitoring, intravenous (IV) pumps, epidural pumps, phones, call lights, in- fant security alarms, infant warmer alarms, and visitors presenting at the doors of locked units all generate various visual and audible notifications to labor nurses. 10 Few studies have been done about electronic alarms in the labor and birth setting. Consistent with the results of research con- ducted in the ICU setting, 2,7,9 the majority of EFM alarms during labor are nonactionable and false, mostly due to brief periods of loss of signal rather than concerning changes in the fetal heart rate (FHR) pattern that warrant intrauterine re- suscitation measures. 10Alarms vary significantly based on the EFM surveillance vendor in use on the labor unit, as there are no standards on ma- ternal or fetal alarm parameters and each of the Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 66 www.jncqjournal.comJ Nurs Care Qual• Vol. 34, No. 1, pp. 66–72 • Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. January-March 2019 • Volume 34 • Number 1 www.jncqjournal.com67 7 companies that offer EFM surveillance systems uses different parameters. 10 Overmonitoring 11 ,12 is likewise an issue, as many women in labor are not candidates for con- tinuous EFM based on their low risk status, yet are routinely monitored. 13 ,14 This overmonitor- ing has been linked to unnecessary interventions including cesarean birth. 13 PURPOSE The purposes of this study were to explore sim- ilarities and differences in perceptions of clini- cal alarms by labor nurses caring for generally healthy women compared with perceptions of adult ICU and neonatal ICU (NICU) nurses car- ing for critically ill patients and to seek nurses’ suggestions for potential improvements. The ul- timate goal of the research is to develop alarm parameters for maternal and fetal status via EFM with acceptable specificity, so labor nurses can be more confident in EFM alarm data and use EFM systems to enhance patient safety. METHODS Setting and participants Two hospitals were used as clinical sites for this study. Site A is a 787-bed community teach- ing hospital in a suburban setting in the Mid- west, with 7 adult ICUs, a NICU with 95 sin- gle rooms/120 beds, and a maternity service with over 9000 births. Site A has a virtual electronic ICU (eICU), which provides 24-hour surveillance by physicians and nurses of critically ill patients via cameras and physiologic data streams across the 4 states the health care system serves. Site B is a 183-bed urban maternity and pediatric teach- ing hospital in the Western area of the United States with over 2400 births. Both sites have new maternity units (built in 2013 and 2015, respec- tively) equipped with the latest monitoring tech- nology. Sites A and B have different vendors for their EFM surveillance system. Site B was in- cluded to explore any possible variances in par- ticipant responses based on EFM system vendor since alarm parameters differ by vendor. The inclusion criterion for participants was currently practicing as a staff nurse on their spe- cialty unit. Staff nurses in the adult ICU, NICU, and labor and birth units were recruited to par- ticipate via an e-mail from their nurse manager explaining the purpose of the study, its voluntary nature, details of their potential participation, and date, time, and location of the focus groups.The first 10 nurses on each unit who responded to the e-mail and agreed to participate were given information that they were confirmed as partic- ipants. An e-mail reminder was sent the day be- fore focus groups to confirmed participants. In- stitutional review board approval was obtained at each site. Design and data collection This was a descriptive qualitative study con- ducted using focus groups. Discussions followed a semistructured guide (Supplemental Digital Content, Table 1, available at:http://links.lww. com/JNCQ/A436) and were held at the 2 sites. After obtaining written informed consent and confirming inclusion criterion, nurses in each of the focus groups were asked about what types of alerts and alarms are common in their clini- cal setting, if they were helpful, if they presented challenges, and suggestions for improvement. Two experienced nurse scientists with expertise in patient safety, qualitative research methodol- ogy, and clinical backgrounds in labor and birth developed the questions based on their exper- tise, review of alarm and alert literature, and re- view of EFM vendor alarm parameters. Focus groups lasted 90 minutes each. Discussions were tape-recorded and professionally transcribed verbatim, and transcripts were cross-checked against recordings for accuracy. Field notes were taken. Analysis Transcripts and field notes were reviewed by the research team. Potentially identifying informa- tion, such as mention of a specific vendor, clin- ician, or hospital, was deleted. Inductive coding methods 15 along with thematic analysis of par- ticipants’ responses 16 were used. The 2 investi- gators developed initial coding. The lead author merged key concepts and quotations generated from the data. Themes were identified, reviewed, and refined in an iterative process until consensus was reached. Two nurse focus group participants reviewed the thematic analysis and agreed that findings were consistent with their recollection of the discussion and overall gestalt of the focus groups. Credibility (trustworthiness) of findings was supported by similarity of themes identified independently by the researchers and validation via informant feedback. Authenticity was main- tained by ensuring the selected data elements rep- resented the range of participant voices. Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 68False Alarms and OvermonitoringJournal of Nursing Care Quality RESULTS Seventeen labor nurses (2 groups; n=8 and n=9), 8 NICU nurses (1 group), and 8 adult ICU nurses (1 group) participated in focus groups at site A. Six labor nurses participated in 1 focus group at site B. Participants’ experience as nurses in their specialty varied based on clinical set- ting, with NICU nurse participants most experi- enced (mean, 19.9 years; range, 1-32 years), fol- lowed by labor nurses (mean, 10.2 years; range, 3-35 years), and adult ICU nurses (mean, 4 years; range, 2-7 years). Types of alerts and alarms Nurses in each clinical setting reported alerts and alarms for medical devices specific to their specialty as well as routine vital sign monitor- ing. All reported use of monitors with alarms that measured physiologic parameters includ- ing oxygen saturation, respiratory rate, heart rate, and electrocardiography, IV pumps, and hospital-issued smartphones. Devices specific to the specialty included ventilators and enteral feeding pumps (ICU and NICU), infant warm- ers and infant security systems (labor and birth unit and NICU), bed and chair alarms (ICU), and EFM (labor and birth). Adult ICU nurses had interactions with the eICU. This list is not all inclusive, rather those devices mentioned by participants. Themes There were many commonalities among re- sponses about clinical alerts and alarms of partic- ipants representing all 3 specialties. Nurses gen- erally shared the same concerns. Distinctions be- tween comments of nurses in each specialty were limited to specific devices used on their unit. Four underlying themes emerged: alarm fatigue, im- pact of alarms on patients and family, implica- tions for patient safety, and suggestions for im- provement. No differences were noted in labor nurses’ responses based on the EFM surveillance system vendor. Alarm fatigue Nurses reported auditory and visual notifica- tions from multiple devices. There was consen- sus among participants that there were too many alarms in their clinical setting, and it was diffi- cult to maintain a real-time sense of those that were important to patient safety and those that were nonactionable or low priority. They dis-cussed being overwhelmed by the sheer volume of alarms: “We have so many things … all kinds of auditory stimuli.” An NICU nurse stated: “Ev- erything alarms in the NICU: our ventilators alarm, our IV pumps alarm. Alarms are going off constantly,” and “The phones are ringing, IVs are going, vents going, regular alarms going, the tube station and tube feeding beep … it’s just too much” (ICU nurse). Nurses discussed tuning out the sounds and flashing lights and banners on the computer screen: “I don’t pay attention to the alarms (la- bor nurse).” They reported lingering effects of the sensory overload, for example, “When you go home at night, you can still hear it all” and “Sometimes I dream about dings.” Nurses indi- cated that duration of time and repeated expo- sure to the alarms resulted in less attention to the data being generated and less action as a result of alarm data. “You can sit next to a ringing bell and not hear it, because it’s overwhelming” (ICU nurse). False alarms were commonly discussed and how over time they are ignored by the nurses: “The baby alarm goes off all the time. Two, three times an hour … several times a day … at least 5 times in a shift”(labor nurse); “It may be an ar- tifact or may be that someone is in there giving care, and the nurse will not get up to attend to it because they didn’t witness it” (NICU nurse); and “If someone is alert and awake, but they’re still in the ICU for some reason, and the apnea alarm keeps on going off, by the end of the shift, I’ve tuned it out after hearing it all day” (ICU nurse). Nurses in adult ICUs and NICUs reported changing clinical alarm parameters based on pa- tient condition to minimize false alarms and therefore the potential for alarm fatigue, while labor nurses indicated this was not a common practice. “We usually set our parameters for heart rate, respiratory rate, blood pressure, all sorts of things like that depending on patients’ condition and what protocol they are on” (ICU nurse); “You can choose your alarm limit; set your heart and respiratory rate limits. It’s my patient and I’m responsible for the parameters” (NICU nurse); and “Some of the parameters that are set with these alarms don’t make sense because it’s normal for a baby to be above 160 [bpm, beats per minute] for a minute because the baby is moving around. We don’t set [alarm] pa- rameters” (labor nurse). Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. January-March 2019 • Volume 34 • Number 1 www.jncqjournal.com69 Impact of alarms on patients and families Nurses in all specialties were concerned about the impact of alarms on patients and families. They acknowledged alarms caused worry and stress. “Is something wrong with our baby? I’ve had patients ask that all the time” (labor nurse). “Visitors get upset that you’re not re- sponding to the alarms quick enough, but we know there is nothing wrong” (ICU nurse). How- ever, over time, nurses noted that patients’ fam- ilies adjust and develop resilience to the early stress of the alarms. “Initially parents are terri- fied of every alarm that goes off, and they stare at their baby. After a couple of weeks, they’ll have visitors and say, ‘Oh don’t worry about it.’” (NICU nurse). “Patients’ families watch you, and they see you hit the silence button. The next thing you know, you’re thinking, ‘I haven’t heard an alarm in there for a while,’ and families are in there silencing your alarms” (ICU nurse). Labor nurses likewise reported family mem- bers silencing alarms without letting the nurse know. Nurses mentioned patient education and ex- planations about alarms as a way to minimize patient concerns and reduce anxiety. They de- scribed ways to share information with patients and families. “I definitely give patients the dis- claimer when I’m orienting them to the room. Otherwise I have a lot of them concerned about something being wrong with their baby” (la- bor nurse). “As long as they realize that every sound they hear in their room isn’t their baby, they’re good”(NICU nurse). “You have to tell them [families] what the alarm means and then they calm down” (ICU nurse). Implications for patient safety Labor nurses noted minimal to no reliance on EFM alarms to guide clinical care, rather than focusing on a visual inspection of the FHR trac- ing. Their comments on alarms were mainly cen- tered on the nuisance and nonhelpful aspects of data generated from devices used on the labor unit. “It’s annoying. I hate seeing flashing on ev- erybody else’s strip. It’s like something is wrong and nobody’s doing anything to fix it, but noth- ing is wrong because the FHR is fine.” Labor nurses did not see value in EFM alerts for pa- tient safety and ignored them for the most part. They explained: “I’ve always practiced by just looking at my strip and reacting to what I’m see- ing, not hearing,” and “You have more nuisancealarms so I’m spending a lot of time acknowledg- ing things that are a loss of signal.” Nurses in the NICU indicated that they used several physiologic parameters to know whether the baby was doing well, rather than respond- ing to abnormal values for one parameter such as oxygen saturation. They actively addressed a low heart rate or low oxygen saturation in ba- bies with an impending discharge because these events could have major implications if they de- lay discharge: “If they document it as a brady- cardic or desaturations episode, it can potentially prolong their hospitalization.” Adult ICU nurses noted that most alarms were not of a serious nature and did not require im- mediate action. They relied on the collective ef- forts of the team to be aware of the alarms. “I have a trust factor with my coworkers that some- one has glanced up and miraculously it works. I don’t think I can ever say that there’s been a life-threatening alarm where somebody has not responded in a timely fashion.” However, ICU nurses acknowledged that being busy combined with being overwhelmed with nuisance or false alarms can cause nurses to miss potentially im- portant changes:“I have to admit there are times that somebody may have been bradycardic all day, and I may not have noticed it. That hap- pens.” Adult ICU nurses were especially attuned to bed and chair alarms and responded to those immediately: “There are very few bed alarms that are false. Typically, when I hear a bed I immediately run.” These nurses interacted with nurses from the eICU and generally found them to be helpful: “They’re another set of eyes.” However, at times, they believed the eICU nurses did not give them a chance to respond before calling them. Suggestions for improvement in clinical alerts and alarms Labor nurses wanted to be notified of accurate data that were actionable and related to pa- tient safety.Several offered specific FHR pat- tern parameters they thought would be useful: “I want to know about recurrent variable [deceler- ations] for 10 minutes (because you don’t want to know if there’s just 1 little variable), prolonged decelerations, bradycardia below 90 [bpm] or tachycardia above 170 [bpm], minimal variabil- ity for greater than 30 minutes, tachysystole for 20 minutes, a rising intrauterine pressure base- line via IUPC for an hour.” Some mentioned that Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 70False Alarms and OvermonitoringJournal of Nursing Care Quality individualizing parameters based on patient con- dition might be worthwhile in generating more useful alarm data. Visual alerts were preferred over audible alerts, as labor nurses were focused on visual as- sessment of the FHR tracing and found audible alarms to be a nuisance to themselves and pa- tients: “I would love to see more visual alerts rather than auditory. I think I’m immune to them. I don’t hear it, I look at the strips.” Some labor nurses preferred that the alerts and alarms not be generated in patient rooms to avoid dis- turbing patients and causing them unnecessary worry, for example, sending “all alarms straight to our phone.” Although nurses at one site re- ported generally having one-to-one staffing for labor, some nurses mentioned better staffing as a solution: “Nurses can’t respond to all their alarms because they don’t have time. You can’t be 2 places at 1 time.” Adult ICU and NICU nurses did not offer as many suggestions to remedy the conditions cre- ated by exposure to multiple clinical alarms as did labor nurses. The ICU nurses’ comments re- flected their resignation of working with alarms as part of their routine. One aspect of alarms that NICU nurses would like to improve is sys- tem algorithms to triage clinical alarms. They de- scribed the system being overloaded with mul- tiple abnormal parameters and not being able to appropriately prioritize alarms that may be more concerning. They recommended the sys- tem send the most clinically important alarms first before what they considered to be nuisance alarms. DISCUSSION Staff nurses bear the majority of the alarm bur- den, as they are the direct patient caregivers and interface with alarm-generating devices at the bedside, at the nurses’ station, and via hospital- issued smartphones. In this study, nurses de- scribed being continuously bombarded with the sights and sounds of numerous clinical alerts and alarms. They discussed sounds from nonclinical devices such as phones, the call light system, and the tube station as adding to the ongoing noise in their work environment. Audible alarms seemed to be less appreciated than visual data. Proliferation of medical devices with alerts and alarms in the clinical setting, even for pa- tients who are low risk and likely need minimal to no monitoring, sets the stage for generation ofexcessive notification data, which leads to alarm desensitization, alarm fatigue, and challenges for clinicians to distinguish what is clinically relevant, what is actionable, and what requires an immediate response. In this context, an alarm of clinical importance can be missed and patient safety is at risk. 12 Nurses in this study noted that, as their day went on, they became less attentive to the numerous alarms, consistent with results of a recent study of pediatric ICU nurses in which every subsequent hour of the nurses’ shift was associated with a 15% longer response time (6.1 minutes during the second hour compared with 14.1 minutes in the eighth hour). 7 Overmonitoring may be a contributing fac- tor to production of massive amounts of nonac- tionable, clinically irrelevant data, 12 as in each specialty unit, there appeared to be routines for universal monitoring of numerous physiologic data for all patients. While some nurses men- tioned adjusting alarm parameters based on pa- tient condition, they did not discuss selectively choosing which physiologic values to monitor on an individual patient basis. Nurses seemed resigned to routine use of medical devices with alarms and mentioned several endurance strategies to manage their use. These included relying on team members to help identify alarms that signaled a true patient emergency requiring a bedside response, tuning out most of the noise and focusing on the pa- tient, and critically assessing the entire clinical picture rather than 1 abnormal physiologic value that was alarming. They were sensitive to patients and families needing an explanation of the alarms to minimize their worry and stress. Nurses observed rapid patient desensitization to the alarms, as patients and families realized the vast majority were not significant. Some families were noted to take an active role in silencing alarms, which could compromise patient safety. Nursing implications Nurses suggested several ways to improve the interactions with clinical devices and their as- sociated alarm systems including better technol- ogy, more accurate data, algorithms to triage and prioritize alarm notification, limiting alarms to clinically relevant events, and systems that mini- mize intrusion, noise, and worry for patients and families. Nurse staffing was mentioned as a bar- rier to rapid response to alarms, consistent with Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. January-March 2019 • Volume 34 • Number 1 www.jncqjournal.com71 the findings of studies of evaluating factors influ- encing nurse alarm response. 7One-to-one care during labor was noted as desirable. The premise of clinical alarms is to warn nurses and other caregivers of potentially negative changes in pa- tients’ conditions that will prompt a timely re- sponse to avert patient deterioration or harm. However, when nurses are not confident in accu- racy of alarm data and the data generated are so excessive that it is hard to determine which have clinical relevance, this premise is not reality. Our findings, using the voices of practicing staff nurses, confirm there is much more to be done to improve the nursing work environment relative to use of medical devices with clinical alarms. A work environment characterized by vi- sual and auditory overstimulation of mostly ir- relevant nonactionable data is not conducive to patient safety. Nursing energy trying to tune out noise and flashing of meaningless information, to find data of value that requires a response, could be better spent on patient-specific clinical care. In the context of a busy specialty unit, these conditions may increase risk of preventable pa- tient harm. Development and testing of mater- nal and fetal physiologic alarm parameters that labor nurses would find helpful and that avoid false notifications is needed. Limitations The study has limitations. Although themes gen- erated from the focus groups are consistent with findings of others about alarms in the ICU setting, 1,4,6,7,9,17,18 participants were from 2 hos- pitals and cannot be assumed to represent per- ceptions and experiences of nurses in other fa- cilities with different characteristics and patient populations. Participants worked in units that were relatively new and perhaps had more so- phisticated monitoring technology than the aver- age US hospital. The sample size and the number of groups were relatively small. However, other studies have demonstrated that themes are gen- erated quickly in focus groups, and 3 groups are enough to generate the most prevalent themes. 19 This along with the consistency of our findings with other ICU setting 20 findings suggests some transferability. CONCLUSIONS Clinical alerts and alarms continue to be a problem, even in new hospitals with sophisti- cated technology. Newer systems that allow fortrended data rather than isolated abnormali- ties, and delays in reporting data that were fol- lowed by a return to expected parameters, were not reported being used. Accuracy issues and false alarms are ongoing threats to patient safety. Nurses’ lack of confidence in devices’ alarm sys- tem data is a basis for the timeliness of their re- sponses. When everything is alarming, nothing is alarming: it is hard to know which alarms are significant or vital to patient well-being when there are so many alarms being generated. The sheer volume of visual and audible signals nurses are bombarded with each shift does not appear to have created safer conditions for patients, as nurses routinely tune them out and ignore them. Nurses in each unit noted certain types of alarms that would cause them to respond im- mediately, but the vast majority were not found to be helpful or contribute value to their clini- cal assessment or planned nursing care. Monitor- ing only those patients who need monitoring and only those physiologic values that are warranted based on patient condition may decrease alarm burden. Nurse staffing based on patient acuity is recommended. Nurses desire fewer alerts and alarms with much higher specificity and clinical relevance. Alert and alarms data should be accurate, ac- tionable information that promote patient well- being and minimize risk of preventable harm. Purchasers such as hospitals and health care systems must demand more from medical de- vice vendors; accuracy and better specificity are achievable goals. Nurses should actively partic- ipate in product development. The original in- tent of development of clinical alerts and alarms as patient safety features has not yet been fully realized. REFERENCES 1. Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on pa- tient safety.Curr Opin Anaesthesiol. 2015;28(6):685-690. 2. Drew BJ, Harris P, Zegre-Hemsey JK, et al. 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