Caution On Hospital “Alarm Fatigue”

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 warning noises they hear, leading them to either ignore or disable them. In many instances, an alarm is not providing clinically relevant information.

  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.

Officials with two of California's biggest hospital systems said they were cognizant of the report and were looking into thinning the number of alarms their medical instruments emit.

“We are aware of these new recommendations and are beginning a process to evaluate a systemwide approach that further ensures the safety of patients,” said Elizabeth Mahler, M.D., vice-president of clinical transformation for Sacramento-based Sutter Health, which operates 29 hospitals in Northern California.

Oakland-based Kaiser Permanente, which operates 30 hospitals throughout California, said in a statement that it is “pleased the Joint Commission is highlighting this issue, which we have been addressing in our own facilities for several years. 

“We are making good progress to further enhance our integrated systems, and we are looking at next-generation technology that would help us build on our efforts.”