Alarm Fatigue In Hospitals: Sentinel Event Alert
April 10, 2013

Patient Safety May Be At Risk Due To Alarm Fatigue

Jason Pierce, MSN, MBA, RN for — Your Universe Online

A Sentinel Event Alert issued by The Joint Commission suggests that nurses, physicians and other health care providers can become desensitized to the sound of alarms alerting them to potentially dangerous conditions involving their patients. The report uses the term “alarm fatigue” to describe the phenomenon potentially responsible for over 500 deaths over a five year period.

The Joint Commission defines a sentinel event as, “An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” The use of the term sentinel refers to the need for immediate investigation and response. Sentinel Event Alerts are reports designed to identify specific types of sentinel events, describe their common underlying causes, and suggest steps to prevent occurrences in the future. Organizations accredited by The Joint Commission are encouraged to consider these reports when developing policies and procedures and, if necessary, implement the suggested strategies or reasonable alternatives.

This alert refers to auditory alarms incorporated into many types of medical devices. The alarms are primarily designed to report abnormal function of the device or physiologic changes in the patient. Some examples include; heart rate alarms on ECG monitors, occlusion alarms on intravenous infusion pumps, bed alarms designed to signal that the patient is climbing out of bed, ventilator alarms, and alarms on devices designed to monitor breathing.

According to the report, hundreds of these alarms may be heard for each hospitalized patient every day, and thousands of alarms may sound on an average unit in a given day. Anywhere from 85 to 99 percent of these thousands of beeps and pings each day may not be related to an actual need for intervention. Reasons for these false alarms include inappropriate alarm settings, the use of default settings that do not apply to the particular patient, problems with sensors or displacement of probes. “As a result,” according to the report “Clinicians become desensitized or immune to the sounds, and are overwhelmed by information — in short, they suffer from “alarm fatigue.”

This alarm fatigue can result in health care providers ignoring alarms or failing to respond in an appropriate timeframe. The report describes the case of a 60-year old male patient who died in and intensive care unit after it took the staff over an hour to respond to an alarm indicating a decline in his condition. According to the authors, “This unanticipated death was the result of a significant problem that occurs every day, in many hospitals in the country — a failure to respond to appropriate alarm signals in a timely manner.”

Another consequence of this overwhelming noise is that health care providers may reduce the volume of alarms or adjust the settings outside of the safe limits for their patient. In fact, there were 98 alarm-related sentinel events reported to The Joint Commission between January 2009 and June 2012. Four major contributing factors identified for those events were absent or inadequate alarm systems, improper alarm settings, alarm signals not audible in all areas, and alarm settings inappropriately turned off.

Alarm fatigue was the most common contributing factor identified by the report. Other factors included alarm settings that are not customized to the individual patient or patient population, inadequate staff training, and equipment malfunctions and failures.

This Sentinel Event Alert is not the first report to call attention to alarm-related injuries or deaths. The ECRI Institute has been reporting on such problems since 2007. Alarm-related problems regularly rank as first or second on that organization´s annual “Top 10 Health Technology Hazards” list. “We´ve reported the problem for many years and sought ways to bring the issue to larger prominence,” says James P. Keller, M.S., vice president of health technology evaluation and safety, ECRI Institute. In addition, the U.S. Food and Drug Administration´s database of alarm related deaths includes 566 alarm-related patient deaths between January 2005 and June 2010. Many experts believe this may reflect an under reporting of these events.

The report makes recommendations to reduce patient injuries related to alarm systems. First, leadership within each facility should ensure that there is a process for safe alarm management and response in high-risk areas. Also, guidelines should be developed to address alarm settings on medical devices used in high-risk environments, and identify situations when alarm signals are not clinically necessary. Additional guidelines should address tailoring alarm settings and limits for individual patients. The report lists a number of other strategies designed to address this problem, and is considering the development of a National Patient Safety Goal that would force accredited organizations to implement the recommended changes.

The Joint Commission is one of the largest and most recognized accreditation providers for health care organizations in the United States. Certification or accreditation is based on an organization´s commitment to meeting performance standards developed by The Joint Commission. There are currently over 20,000 health care organizations recognized by The Joint Commission.