Alarms are a serious matter in busy hospitals and ERs punctuated 24/7 by the din from cardiac monitors, IV machines, ventilators and other devices. Some alarms are inconsequential. Some are malfunctions. Others signal impending crisis. Many are simply not heard.
The sheer number of devices with alarms – ECG machines, pulse oximetry devices, BP monitors, telemetry, infusion pumps and ventilators, to name a few. According to the Joint Commission, one single patient can set off literally several hundred alarms each day, depending on the severity of their condition and as few as 1 percent of all alarm signals even require clinical intervention. The resulting problem has been given a name by practitioners and researchers: alarm fatigue.
Both technology and behaviors appear to be at the root of the problem. For example, too many varied alarms, both minor and major, simply sound alike.
While most staff recognize the critical role alarms play, they often become desensitized to alarms and overwhelmed by all the noise. They may sometimes set alarm conditions too high, turn alarm volumes down or off, or neglect to adjust alarm default settings for specific patients or populations. In some
instances, staff may not hear an alarm because a door may be closed or they may be distracted and might hear the alarms only after a significant amount of precious minutes have lapsed. In other instances, a series of cascading “minor” alarm failures are the culprit. By the time an alarm signals a truly critical event – it might be too late.
In April of 2013, the Joint Commission issued a Sentinel Event Alert advising hospitals to take measures like preparing an inventory of alarm-equipped medical devices and tailoring alarm settings and limits for individual patients. Recommendations include:
- Inventory all alarm-equipped medical devices and identify proper default settings and limits.
- Establish guidelines for alarm settings, and indicate when alarms are not “clinically necessary.”
- Also, establish guidelines for safely customizing alarm settings for individual patients and restoring them to default when finished.
- Set up an inspection, cleaning and maintenance program for alarm-equipped medical devices, and test them regularly.
- Orient staff on your organization’s process for safe alarm management and response in high-risk areas.
- Routinely change single-use sensors to avoid false or nuisance alarms.
- Determine whether the acoustics in patient care areas allow alarms to be easily heard.
- Set your priorities for replacing aging monitors with newer technology.
- Establish a multi-disciplinary team of clinicians and representatives from clinical engineering, information technology and risk management to address alarm safety and management.
- Share information about alarm-related incidents, prevention strategies and lessons learned.
In addition, a National Patient Safety Goal by the Joint Commission, effective January 1, 2014, gave hospitals two years to put new clinical alarm policies in place. Essentially, this includes any medical devices that have visual and/or auditory alarms. The goal was implemented in two phases. The first phase, effective January 1, 2014 charged hospital leaders with collecting input on alarm signal management from frontline staff and compiling best practices. The second phase, effective January 1, 2016 required hospitals to have specific policies for alarm safety in place.
Action for Better Healthcare Blog from Premier Inc.
- Blog by Gina Pugliese: Part 1 Sounding the alarm on alarm fatigue
- Blog Part 2 10 ways to reduce alarm fatigue
White papers, as part of the HTSI’s “Safety Innovations” series, highlight alarm safety issues:
- AAMI Clinical Alarm Management Compendium to meet Joint Commission Goals 2015
- Case study: alarm management at Beth Israel Deaconess Medical Center
- Case study: several major initiatives to reduce hazardous situations related to alarm systems at Johns Hopkins Hospital
- Case study: alarm signal standardization at Christiana Care Health System
- Priority Issues from the Medical Device Alarms Summit convened by AAMI, FDA, TJC, ACCE, and ECRI Institute (December, 2011)
Agency for Healthcare Quality and Research (AHRQ)
- Patient safety primer: Alert Fatigue (May, 2015)
American College of Surgeons
American Society of Anesthesiologists
ECRI has placed alarm safety on its list of Top Ten Health Technology Hazards for the past six years. To register and access a download of the 2017 report, use this link:
- Medication Safety Alert (March, 2013)
National Association of Clinical Nurse Specialists
- First National Survey of Patient-Controlled Analgesia Practices (October, 2013)
- Checklist: PCA Safety Checklist (word) (pdf)
- Patient Safety Experts Share 4 Insights About Safer Opioid Pain Management.
- Making the Case for Maximum Alarm Management and Prevention of Alarm Fatigue
Premier’s Action for Better Healthcare Blog
Alarm safety by Gina Pugliese