The Joint Commission Targets Alarm Fatigue

Alarm fatigue—the desensitization of medical staff to the nonstop assault of alarm tones coming from a multitude of electronic monitoring devices—is dangerously on the rise in hospitals across the U. S. and is now considered one of the top safety issues. In response, The Joint Commission has issued a Sentinel Event Alert and is exploring possible additional strategies, including the development of a National Patient Safety Goal, to address this problem.

Equipping electronic monitoring devices with automatic alarms is an important aspect of safe patient care. Alarms play a vital role in alerting health care staff when these monitors require attention. However, thousands of similarly sounding alarms may go off on any unit on any given day. Perhaps only 1% of these alarms require clinical intervention, so clinicians can easily become immune to these alarms, thus the term “alarm fatigue.”

Causes of Alarm-related Incidents

Alarm fatigue among healthcare workers isn’t a new concern. The Joint Commission first identified it as a patient safety issue in 2004. After an investigation by the Boston Globe reported that alarm fatigue had played a role in the deaths of more than 200 hospital patients, the issue resurfaced.

Working with the ECRI Institute, a nonprofit healthcare research and consulting organization, the Globe concluded that alarms on patient monitors sounded so often and false alarms were so common that nurses no longer reacted to them. In one 15-bed unit at Johns Hopkins Hospital, for example, staff members documented an average of 942 alarms a day—the equivalent of one critical alarm going off every 90 seconds. In some cases, clinicians may have turned down the volume of an alarm, adjusted alarm settings beyond the limits appropriate for the patient, or turned off the alarm entirely. Any of these actions can result in serious and sometimes fatal outcomes.

In its annually published report “Top 10 Health Technology Hazards,” ECRI Institute consistently lists clinical alarm conditions as the first or second most critical hazard, reflecting both the frequency and serious consequences of alarm-related problems. The Joint Commission’s Sentinel Event database lists 80 deaths, 13 cases of permanent loss of function, and 5 cases of unexpected additional care or extended stay resulting from alarm-related events between January 2009 and June 2012. Alarm fatigue was the most common contributing factor in these events. Other factors included alarm settings that had not been customized to the individual patient, inadequate training on the proper use of the equipment, inadequate staffing to respond to alarm signals, alarm conditions and settings that were not integrated with other medical devices, and equipment malfunctions and failures.

Addressing the Problem

The Joint Commission recommends facility leadership and a multidisciplinary approach to minimize the potential for patient harm. Specific recommendations include:

  • maintaining an inventory of alarm-equipped medical devices, identifying default alarm settings and the appropriate limits for each care area, and ensuring a process for safe alarm management and response in high-risk areas
  • creating guidelines for alarm settings that include identifying situations when alarm signals are not clinically necessary and tailoring alarm settings for individual patients so that settings can be appropriately modified to minimize the number of alarm signals
  • performing inspections and maintenance on alarm-equipped devices to ensure proper operation, appropriate alarm settings, and detectability
  • providing adequate training on the safe use of alarmed medical devices to all members of the clinical care team
  • changing single-use sensors to help reduce nuisance alarm signals
  • ensuring that critical alarm signals in patient care areas can be heard
  • reassessing priorities in adopting alarm technology so that adding new technology is driven by patient care priorities, not by technology
  • setting up a cross-disciplinary team of clinicians and representatives from clinical engineering, information technology, and risk management to address the potential impact of alarm fatigue in all patient care areas
  • establishing a process to continually improve alarm system policies by reviewing trends in alarm-related events
  • sharing information about alarm-related incidents, prevention strategies, and lessons learned with appropriate organizations, such as The Joint Commission, ECRI Institute, the Association for Advancement of Medical Instrumentation, and the Food and Drug Administration.

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