TJC warns about alarm fatigue putting patients at risk

The constant beeping of alarms and an overabundance of information transmitted by medical devices such as ventilators, blood pressure monitors and ECG (electrocardiogram) machines is creating “alarm fatigue” that puts hospital patients at serious risk, according to a Sentinel Event Alert issued recently by The Joint Commission (TJC).

The TJC alert urges leaders at hospitals to take a focused look at this serious patient safety issue. Over a recent four-year period, a Food and Drug Administration (FDA) database shows that there were more than 560 alarm-related deaths. The Joint Commission’s sentinel event database includes reports of 80 alarm-related deaths and 13 serious alarm-related injuries during a similar period. (The alert is available online at http://www.jointcommission.org/sea_issue_50.)

Many patient care areas have numerous alarms, and the barrage of warning noises tend to desensitize caregivers and cause them to ignore alarms or even disable them, TJC noted. Other issues associated with effective alarm management include too many medical devices with alarms or individual alarms that are difficult to hear. Pre-set or default settings also might cause problems because the device sounds a warning even when no action or decision by a caregiver is required. Rather than calling attention to a patient’s needs, these settings might distract caregivers.

TJC recommends that healthcare organizations take the following actions:

• Ensure that there is a process for safe alarm management and response in areas identified by the organization as high risk.

• Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and the limits appropriate for each care area.

• Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions; include identification of situations when alarm signals are not clinically necessary.

• Establish guidelines for tailoring alarm settings and limits for individual patients.

• The guidelines should address situations when limits can be modified to minimize alarm signals and the extent to which alarms can be modified to minimize alarm signals.

• Inspect, check, and maintain alarm-equipped medical devices to provide for accurate and appropriate alarm settings, proper operation, and detectability.

• Base the frequency of these activities on criteria such as manufacturers’ recommendations, risk levels and current experience.

The Joint Commission alert also recommends training and education for all clinical care team members on safe alarm management and response in high-risk areas. In addition, organizations should consider how to reduce nuisance alarm signals and to determine whether critical alarm signals can be heard in patient care areas. TJC has proposed a National Patient Safety Goal to help healthcare organizations address this issue. (Editor’s note: To see how alarms played a role in a recent court case, see “Dialysis mistakes lead to a wrongful death and a seven-figure settlement” in this month’s Legal Review & Commentary supplement.)