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, TJC 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, TJC has included Clinical Alarm safety as a component of its National Patient Safety Goals (NPSGs) since 2014. Starting January 1, 2019, the current NPSG’s address Clinical Alarm Safety as NPSG .06.01.01. The standards include education of both staff and licensed independent practitioners.
White Papers, as Part of the HTSI’s “Safety Innovations” Series, Highlight Alarm Safety Issues
- AAMI Clinical Alarm Management Compendiumopens in a new tab to meet Joint Commission Goals 2015
- Case study: alarm management at Beth Israel Deaconess Medical Center PDF opens in a new tab
- Using Data to Drive Alarm System Improvement Efforts: The John Hopkins Hospital Experience PDF opens in a new tab
- Case study: alarm signal standardization at Christiana Care Health System PDF opens in a new tab
- Priority Issues from the Medical Device Alarms Summit convened by AAMI, FDA, TJC, ACCE, and ECRI Institute PDF opens in a new tab (December, 2011)
Agency for Healthcare Quality and Research (AHRQ)
American College of Surgeons
American Society of Anesthesiologists
Anesthesia Patient Safety Foundation (APSF)
- Alarm Fatigue and Patient Safetyopens in a new tab (June, 2019)
Initiatives in Safe Patient Care
Physician-Patient Alliance for Health and Safety
- opens in a new tabFirst National Survey of Patient-Controlled Analgesia Practices PDF opens in a new tab (October, 2013)
- Checklist: PCA Safety Checklist (Download PCA Safety Checklist inWord) (Download PCA Safety Checklist inPDF)
- Patient Safety Experts Share 4 Insights About Safer Opioid Pain Management.opens in a new tab
- Making the Case for Maximum Alarm Management and Prevention of Alarm Fatigue (January, 2014)