Joint Commission Issues Advisory On Medical Alarms

The Joint Commission has issued a warning about too many warnings.

The Oakbrook Terrace, Ill.-based organization that surveys and accredits most of the nation's hospitals alerted its membership on Monday about the dangers posed by an excess of alarms that go off in inpatient settings.

Joint Commission officials said they were prompted to issue the “Sentinel Event Alert” after the U.S. Food and Drug Administration showed that there were more than 560 patient deaths in a recent four-year period linked to “alarm fatigue” – the phenomenon of hospital employees ignoring alarms from medical devices that monitor patients because they have heard them over and over again. Another 80 deaths and 13 serious injuries had been placed into the Joint Commission's sentinel event database during the same period.

According to Joint Commission officials, caregivers tend to be desensitized by the barrage of warningnoises they hear, leading them to either ignore or disable them. Alternatively, there may be instances where alarms can be too difficult to hear. And some devices contain presets that may cause it to sound warnings even when no action is required by the caregiver.

“Alarm fatigue and management of alarms are important safety issues that we must confront," said Ana McKee, M.D., the Joint Commission's chief medical officer.

The Joint Commission has made the following recommendations:

• 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 Joint Commission also recommended that hospitals reduce the number of nuisance alarms emitted by medical devices, and properly assess if critical alarms emitted by medical devices can actually be heard by the appropriate hospital employees.