'Alarm fatigue' endangers patients

Joint Commission issues warning on 'serious risk'
By Bernie Monegain
08:01 AM
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The constant beeping of alarms and an overabundance of information transmitted by medical devices such as ventilators, blood pressure monitors and ECG (electrocardiogram) machines is creating "alarm fatigue" that puts hospital patients at serious risk, according to a Sentinel Event Alert issued April 8 by The Joint Commission.

The Joint Commission Alert urges leaders at hospitals to take a focused look at this patient safety issue.

Over a recent four-year period, a U.S. Food and Drug Administration database shows that there were more than 560 alarm-related deaths, and The Joint Commission's sentinel event database includes reports of 80 alarm-related deaths and 13 serious alarm-related injuries during a similar period.

Patient deaths related to alarms on monitoring devices have also been the focus of national media attention and special reports by the Association for the Advancement of Medical Instrumentation and ECRI Institute. The Joint Commission, AAMI, ECRI Institute and American College of Clinical Engineering also brought together patient safety and healthcare experts at a 2011 summit to seek solutions to problems with medical device alarms.
Alarms are intended to alert caregivers of potential problems, but can compromise patient safety if they are not properly managed, according to the Joint Commission.

Leah Binder, president and CEO of watchdog organization Leapfrog, said, she too is concerned about safety.

Speaking as a patient, she said, she is more concerned that a fatal error will be made by a CPOE system than her doctor will get annoyed that the system alerts are too frequent. “Frankly I wish they would be a little more concerned about the patients."

"I understand that alert fatigue is an issue," she said. "I do understand that." However, Binder, whose organization has a long record of monitoring CPOE safety, suggested that hospitals worried about how they are doing, take Leapfrog's free CPOE test.

"We test for alert fatigue," Binder said. "We test for frivolous alerts. So, a system that has too many frivolous alerts is not going to pass Leapfrog’s test."

[See also: The Joint Commission Launches Lab Central Connect Portal.]

Joint Commission officials explained their concern this way in a press statement: “Many patient care areas have numerous alarms and the barrage of warning noises tend to desensitize caregivers and cause them to ignore alarms or even disable them. Other issues associated with effective alarm management include too many medical devices with alarms or individual alarms that are difficult to hear. Pre-set or default settings also may cause problems because the device sounds a warning even when no action or decision by a caregiver is required. Rather than calling attention to a patient's needs, these settings may distract caregivers.”

“These issues vary greatly among hospitals and even within different units in a single hospital,” the Joint Commission noted. Although there are many variables, the Alert makes it clear that in order to reduce risks related to alarms on medical devices, a series of actions still needs to occur related to people, processes and technology.

[See also: Leapfrog sounds alarm on untested CPOE.]

"Alarm fatigue and management of alarms are important safety issues that we must confront," said Ana McKee, MD, executive vice president and chief medical officer, The Joint Commission. "The recommendations in this Alert offer hospitals a framework on which to assess their individual circumstances and develop a systematic, coordinated approach to alarms. By making alarm safety a priority, lives can be saved."

The Joint Commission Alert recommends that health care organizations take the following actions, which correspond with recommendations made by both AAMI and ECRI Institute

  • Ensure that there is a process for safe alarm management and response in areas identified by the organization as high risk.
  • 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. The guidelines should address situations when limits can be modified to minimize alarm signals and the extent to which alarms can be modified to minimize alarm signals.
  • Inspect, check and maintain alarm-equipped medical devices to provide for 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.