Joint Commission alerts hospitals to “alarm fatigue”
■ Injuries and deaths can occur when too many beeping devices numb doctors and nurses to potential dangers.
Medical equipment alarms that beep and buzz throughout hospital units may be a serious threat to the patients they are meant to protect, says a sentinel event alert issued by the Joint Commission.
Without uniform standards and training on what specific alarm sounds mean, doctors and nurses often misinterpret the urgency of alarms on devices such as ventilators and heart monitors. They may improperly adjust settings to reduce noise or become desensitized and ignore them, resulting in serious injury and death, the commission said.
The commission's database logged 80 alarm-related deaths and 13 severe alarm-related injuries from January 2009 to June 2012. Injuries or deaths commonly resulted from falls, medication errors, and delays in treatment and ventilator use.
Because hospitals aren't required to report such alarm-related events, the numbers of deaths and injuries probably are much higher, according to the alert, issued April 8 (link).
The Joint Commission recommended that hospitals take several steps to reduce so-called alarm fatigue. Among them:
- Establish guidelines for tailoring alarm settings and limits for each patient. An elite athlete may have a lower heart rate than the default setting for triggering an alarm, for instance.
- Inventory all alarms in high-risk areas.
- Inspect, check and maintain alarm-equipped medical devices. Base frequency of alarms on criteria such as manufacturer recommendations, risk levels and experience.
- Identify situations when alarm signals are not clinically necessary.
Safe alarm management
The most important message behind the alert is for hospital leadership to recognize the severity of the problem and make sure there is a formalized process for safe alarm management, said Ana Pujols McKee, MD, the commission's executive vice president and chief medical officer. Although nurses check the alarms most often, the issue affects everyone who interacts with a patient.
“We think everyone who works in a clinical environment should receive some training on alarm safety,” Dr. McKee said. That extends to training nonclinical staff members on their role when they hear an alarm.
Nancy Foster, vice president of quality and patient safety policy for the American Hospital Assn., applauded the commission for pushing the issue to alert status. She said addressing alarm fatigue goes beyond hospitals.
“This will take action by the manufacturers [and] will take action by all of the caregivers,” she said. “You have to involve your materials management staff so that they're ensuring that the piece of equipment they're considering buying will fit into an alarm management template that a hospital may have chosen to use.”
Dr. McKee said alarm fatigue is a complex problem for hospitals, partly because there is little standardization in the manufacturing of devices and their alarms.
“There are some devices that are designed to alarm when they are functioning and some devices that are designed to alarm when the patient's physical condition has changed,” she said. “That alone … tends to lead to some of the confusion and alarm fatigue.”
Sentinel alerts are issued about three times a year, Dr. McKee said. The commission is considering making reduction of alarm fatigue a national patient safety goal, which would require hospitals to take actions to reduce it to remain accredited.
But Foster is concerned that hospitals have little to go on as far as proven methods for reducing such fatigue.
“Making something a national patient safety goal suggests to me that we have some strategy … that has been well-proven as effective,” she said. “We may need to do a little more homework before this could and should become a national patient safety goal.”