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Joint Commission Report: ‘Alarm Fatigue’ Can Be Deadly

Hospital group offers safety recommendations (Apr. 8)

Many medical devices have alarm systems. These alarm-equipped devices are essential to providing safe care to patients in many health care settings; clinicians depend on these devices for information they need to deliver appropriate care and to guide treatment decisions.

However, according to a new alert issued by the Joint Commission, these devices can present challenges for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.

The number of alarm signals per patient per day can reach several hundred depending on the unit within the hospital, which translates to thousands of alarm signals on every unit and tens of thousands of alarm signals throughout the hospital every day, the commission warns. It is estimated that between 85% and 99% of alarm signals do not require clinical intervention, such as when alarm conditions are set too tight; default settings are not adjusted for the individual patient or for the patient population; electrocardiogram (ECG) electrodes have dried out; or sensors are mispositioned. As a result, clinicians develop “alarm fatigue” — i.e., they become desensitized to the sound of the alarms and are overwhelmed by information.

The Joint Commission’s Sentinel Event database includes reports of 98 alarm-related events between January 2009 and June 2012. Of the 98 reported events, 80 resulted in death, 13 in permanent loss of function, and five in unexpected additional care or extended stay. Common injuries or deaths related to alarms included those from falls, delays in treatment, ventilator use, and medication errors; all were traced back to alarm-system issues. Ninety-four of the reported events occurred in hospitals.

The commission offers the following recommendations to reduce patient harm related to alarm systems:

  • Ensure that there is a process for safe alarm management and response in high-risk areas (as identified by the organization).
  • Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and the limits appropriate for each care area.
  • Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions; include identification of situations when alarm signals are not clinically necessary.
  • Establish guidelines for tailoring alarm settings and limits for individual patients.
  • Inspect, check, and maintain alarm-equipped devices to provide accurate and appropriate alarm settings, proper operation, and detectability. Base the frequency of these activities on criteria such as manufacturers’ recommendations, risk levels, and current experience.

Source: Joint Commission; April 8, 2013.

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