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Joint Commission issues alert on 'alarm fatigue’

Monday April 15, 2013
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The constant beeping of alarms and an overabundance of information transmitted by medical devices such as ventilators, blood pressure monitors and electrocardiogram machines is creating "alarm fatigue" that puts hospital patients at serious risk, according a new alert from The Joint Commission.

The 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 database shows more than 560 alarm-related deaths, while The Joint Commission’s sentinel event database includes reports of 80 alarm-related deaths and 13 serious alarm-related injuries during a similar period.

Alarms are intended to alert caregivers of potential problems, but can compromise patient safety if they are not properly managed, according to a Joint Commission news release. Many patient care areas have numerous alarms, and the barrage of warning noises tends to desensitize caregivers and cause them to ignore alarms or even disable them. Other issues associated with effective alarm management include too many medical devices with alarms or individual alarms that are difficult to hear. Preset or default settings also may 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 may distract caregivers.

These issues vary greatly among hospitals and even within different units in a single hospital, according to the news release. Although there are many variables, the Joint Commission alert makes clear that to reduce risks related to alarms on medical devices, a series of actions needs to occur encompassing people, processes and technology.

"By making alarm safety a priority, lives can be saved," Ana McKee, MD, executive vice president and chief medical officer of The Joint Commission, said in the news release.

The new alert recommends that healthcare organizations take the following actions, which correspond with recommendations made by both the Association for the Advancement of Medical Instrumentation and the ECRI Institute:

• Ensure 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 so modified.

• 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 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 determine whether critical alarm signals can actually be heard in patient care areas. Seeking input from patient care providers, healthcare engineers, risk managers and information technology professionals, organizations also should establish policies and processes for alarm safety that include the regular review of trends and patterns that reveal improvement opportunities.

Finally, the alert urges organizations to share information about alarm-related incidents, prevention strategies and lessons learned with organizations such as AAMI, ECRI, the FDA and The Joint Commission.

Beyond the alert, The Joint Commission is considering the possible creation of a National Patient Safety Goal to help healthcare organizations address this issue. A field review of the proposed goal took place in February, and the public comments are under review. The Joint Commission already has numerous accreditation standards in place related to alarm safety. The standards address issues such as leadership, the environment of care, provision of care and staff training and education.

The warning about medical device alarms is part of a series of alert issued by The Joint Commission. Much of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, described as one of the nation’s most comprehensive voluntary reporting systems for serious adverse events in healthcare. The database includes detailed information about both adverse events and their underlying causes.

Previous alerts have addressed risks associated with the use of opioids, healthcare worker fatigue, diagnostic imaging risks, violence in healthcare facilities, maternal deaths, healthcare technology, anticoagulants, wrong-site surgery, medication mix-ups, healthcare-associated infections and patient suicides, among other topics.

Links to the latest alert and other alerts are available at www.jointcommission.org/sentinel_event.aspx.


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