sentinel event alert to hospitals about the need to reduce "alarm fatigue" related to alarms set off by monitoring devices. This term refers to situations in which clinicians ignore or turn off the alarms that they find irrelevant or annoying.
The accreditation body's decision to make alarm fatigue the subject of a sentinel event report shows that the Joint Commission regards this as a serious patient safety issue. The Joint Commission defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof."
Of the sentinel events reported to the Joint Commission from 2009 to 2012, 98 had alarm-related causes, usually in combination with other factors. "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," the Joint Commission report says.
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Among the specific problems cited in these sentinel events were absent or inadequate alarm systems, improper alarm settings, alarm signals not audible in all areas and alarm settings inappropriately turned off.
The ECRI Institute, in its annual list of health technology hazards, consistently places problems with clinical alarms as the first or second most critical safety problem in hospitals. And a database maintained by the U.S. Food and Drug Administration (FDA) shows that between 2005 and 2010, there were 566 alarm-related patient deaths -- a figure that industry experts believes is far lower than the actual number.
Alarm fatigue exists for a simple reason: too many device alarms (85% - 99%) go off in hospitals for no clinically relevant reason. But the solution to this problem is very complex and must involve both clinicians and monitoring device vendors, the Joint Commission says.
To start, hospitals must take inventory of the device-related alarms going off in high-risk areas like ICUs and EDs. Then they should establish guidelines for the adjustment of these alarm systems for individual patients, according to the Joint Commission.
In an interview with Information Healthcare, Paul Schyve, MD, senior advisor for healthcare improvement at the Joint Commission, noted that he has been in ICUs and EDs where alarms kept going off because they'd been set at a standardized level rather than being adjusted for individuals. "Because everyone knows the alarm isn't relevant to that particular patient, it's appropriately ignored."
Nurses are usually responsible for adjusting the alarm settings, but Schyve noted that it's difficult for them to do that unless the hospital has created guidelines and has properly trained them on the equipment they're using. He said physicians should be more involved in this process, both on the floor and on hospital committees that develop the guidelines.
As for training on how to adjust alarms for individual patients, Schyve said, "There probably isn't a lot of that kind of training being provided." Moreover, when a hospital buys a new medical device or monitor, the staff isn't always fully trained on it. And it's not uncommon for a hospital to have more than one model or brand of an infusion pump or other device, each with its own method of adjusting the alarm settings.
That's one area, Schyve noted, where vendors could help reduce alarm fatigue by standardizing how alarms are adjusted on similar equipment. In addition, vendors could work together to differentiate alarm sounds coming from different devices. "If you have two pieces of equipment that have the same loudness and tone in their alarms, you can't tell easily which one it is."
Some hospitals are beginning to send alarms to smartphones or iPads used by clinicians. This can be valuable, Schyve said, in alerting a physician who is in a different part of the building about a patient who needs help; it can also alert a nurse who is in a different room on the same floor. But unless the alarm limits are set correctly for that particular patient, mobile apps can actually add to the problem.
Overall, Schyve said, hospitals have a long way to go in addressing alarm fatigue. "We're trying to draw more attention to this and suggest there are some things that can be done to help reduce the risk."
Regulatory requirements dominate, our research shows. The challenge is to innovate with technology, not just dot the i's and cross the t's. Also in the new, all-digital The Right Health IT Priorities? issue of InformationWeek Healthcare: Real change takes much more than technology. (Free registration required.)