Blog Post

Doctor, the Patient is in the Control Room

Stephen Reilly

Back in 2007, Dr. Joan S. Ash, et al, published “Some Unintended Consequences of Clinical Decision Support Systems” in the American Medical Informatics Association. The journal article explored the unintended consequences of these devices with computerized physician/provider order entry, citing alert fatigue by the nurses and doctors as one of the thematic causes to incidents studied. More recently, Lindsay Holmwood penned, “If alarms are more often false than true, a culture emerges on the unit in that staff may delay response to alarms, especially when staff are engaged in other patient care activities, and more important critical alarms may be missed.” In the hospital setting, missing a critical alarm could be the difference between a patient’s life and death, leading to situations that no one would want to endure.

In the analogous setting of a plant’s control room, the patient is the control-system-governed process, and the board operators are the medical staff on hand responding to every alarm it receives. Similarly, since 1999, the Chemical Safety Board has documented multiple industrial incidents caused, at least in part, by “alarm floods”, which occur when there are 10 or more annunciated alarms in any 10-minute period per operator. Imagine how plant management feels about an easily-avoidable industrial incident that causes the plant to shut down or worse!

So what can you do to prevent this situation under your staff’s watch? Well, first, it helps to know what qualifies as an alarm. The ISA 18.2 standard defined an alarm as “an audible and/or visible means of indicating to the operator an equipment malfunction, process deviation, or abnormal condition requiring a response”. With that in mind, you then proceed with an alarm rationalization of your process. In doing so, you assess with each process measurement in your plant whether or not each alarm potentially configured for it meets this criteria, disabling those that fail this test. It’s pretty straightforward, but when you repeat it thousands of times per process unit, it can be quite the dreaded medicine to take!

At ProSys, where we frequently make house calls on the DCS, we prescribe only ACCURATE alarms to our patients so that their control systems get back to optimum performance in rapid time! We also make it easier for you to swallow that medicine, by reducing the dosage you actually have to cover. So if you’re looking for healthier operations at your plant, don’t hesitate to give us a call!