Friday, April 12, 2013

Alarm Fatigue

According to a news article published by The Joint Commission, the constant beeping of alarms and the overabundance of information transmitted by medical devices are causing “alarm fatigue” and is putting patients at risk.

Over a four-year period, The Joint Commission sentinel event database reported 80 alarm-related deaths and the U.S. Food and Drug Administration database reported more than 560 alarm-related deaths.

Alarms in patient rooms are there to alert caregivers of potential problems, but if they are not properly managed, safety can be compromised. Warning noises tend to desensitize caregivers and can cause them to ignore alarms or even disable them. Sometimes there are too many medical devices with alarms or individual alarms can be difficult to hear.

The Joint Commission recommends that health care organizations take the following actions:

  • 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.
Since this is a growing issue, The Joint Commission is also considering creating this as a National Patient Safety Goal so health care organizations can be more educated on the matter.  

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