The Joint Commission (TJC) recently published a Sentinel Event Alert (Alert) regarding “alarm fatigue,” which occurs when physicians are so overwhelmed by the constant barrage of medical device alarms, most of which do not require clinical intervention, that they become desensitized to the alarm signals, potentially leading to dangerous delays in treatment. In the Alert, TJC indicates that it is exploring the possibility of developing a National Patient Safety Goal (NPSG) related to alarm-equipped medical devices, and it provides recommendations as to how healthcare organizations can reduce and prevent patient harm related to medical device alarm systems.
Alarm fatigue is very dangerous. Of the 98 alarm-related events reported to TJC between January 2009 and June 2012, 80 resulted in death, 13 resulted in permanent loss of function and five resulted in unexpected additional care or an extended stay. The U.S. Food and Drug Administration (FDA) received 566 reports of alarm-related patient death between January 2005 and June 2010. In addition, according to TJC, alarm-related events are recognized as underreported in all healthcare settings. The ECRI Institute, a federally designated Patient Safety Organization, has consistently listed clinical alarm conditions as the first or second most critical health technology hazard faced by healthcare organizations in its annually published “Top 10 Health Technology Hazards” list.
TJC’s announcement that it is exploring the possibility of developing a NPSG regarding alarm-equipped devices puts hospitals on notice that they likely will need to address this issue in order to remain accredited. To that end, TJC recommends that facilities take the following actions to reduce alarm fatigue:
- Establish Specific Guidelines for Alarm Settings. Avoiding unnecessary alarm signals by ensuring that alarms are triggered only when clinical intervention is necessary can decrease the likelihood of alarm fatigue. Alarm settings should be tailored to each specific patient, and each device’s alarm sound should be individually recognizable.
- Training and Education. Clinicians are more likely to properly set and respond to alarm signals if they understand the organization’s alarm-setting guidelines and processes for safe alarm management. Ongoing education and training for newly acquired or updated devices is critical to ensure clinicians continue safe practices even when the equipment upon which they rely changes.
- Physical Environment and Equipment Assessment. Organizations should assess the environment in which clinicians must decipher alarm signals. For example, do the acoustics of a given patient care area allow critical alarm signals to be audible? Can clinicians differentiate between different alarm signals? Organizations also should seek to avoid nuisance signals by ensuring that equipment is functioning properly and that single-use sensors, such as ECG sensors, are properly positioned and replaced according to manufacturer’s recommendations.
- Leadership and Organizational Prioritization. Organizations should make alarm management a priority and adopt appropriate policies, procedures and information-sharing practices that address alarm-related issues.