TJC: Alarm fatigue is a growing concern

January 12th, 2015

Spend any amount of time in a hospital – as a doctor, nurse, patient, or visitor – and you’ll know that medical device alarms are an almost constant sound. While visiting my friend and her newborn daughter in the hospital last month, the baby’s EKG monitor alarm would sound every time we shifted position while holding her. Since it was an issue with the wires in the leads, is it any wonder that the nurses were desensitized to the sound? Alarms can go off hundreds of times a day in all different hospital areas – and this “alarm fatigue” can lead to hospital staff not knowing which alarms are “false” and which are “real”.

In response, The Joint Commission released a Sentinel Event Alert to warn of patient dangers due to alarm fatigue. "In response to this constant barrage of noise, clinicians may turn down the volume of the alarm setting, turn it off or adjust the alarm settings outside the limits that are safe and appropriate for the patient -- all of which can have serious, often fatal consequences," the alert says.

TJC’s Sentinel Event database shows 98 alarm-related events from January 2009 – June 2012. Of those 98 events, 80 resulted in death, 13 in serious injury, and five in unexpected care or extended hospital stay. Contributing factors included absent or inadequate alarm system; improper alarm settings; alarm signals not audible in all areas; and alarm signals inappropriately turned off.

To address the alarm fatigue problem, TJC is considering options such as a developing a National Patient Safety Goal. Its other recommendations include:

• A process for safe alarm management in high-risk areas
• Guidelines for tailoring alarm signals to individual patients
• Continually train staff on alarm management and response in high-risk areas
• Establishing a cross-disciplinary team to evaluate alarm usage, review data in alarm events, and develop alarm policy and review guidelines.