New Guidelines to Reduce 'Alarm Fatigue'

Lisa Pevtzow

April 16, 2013

Planning, training, and basic machine maintenance were some of the recommendations made by the Joint Commission last week in a report that tackles the chronic problem of medical device alarm safety.

The commission's Sentinel Event Alert also advised healthcare facilities to establish guidelines for alarm settings on medical monitoring devices, such as electrocardiogram machines and blood pressure monitors, and to tailor them for individual patients.

"Healthcare is ridden with a number of problems that never seem to go away," said Ana McKee, MD, executive vice president and chief medical officer of the Joint Commission, an independent nonprofit that accredits and certifies more than 20,000 healthcare organizations and programs in the United States. "This one is actually becoming a more serious problem."

The problem, she said, is compounded by the sheer number of alarmed medical devices, their complexity, and a complete lack of standardization, in which some devices alarm when patients are deteriorating and others when they are working well.

Dr. McKee said there especially needs to be an awareness of the issue by healthcare administrators, who must develop and follow a plan on alarm safety management, she said.

According to the report, medical devices for each hospital patient can generate up to several hundred alarm signals each day, which can mean thousands of alarm signals in a unit and tens of thousands throughout a hospital each day. Of those signals, 85% to 90% are not medically significant, and instead result from wrongly placed sensors, dried-out electrocardiography electrodes, or incorrect settings.

This creates "alarm fatigue," when the daily cacophony of bells, beeps, and tones from medical devices overwhelms medical personnel with information and desensitizes them to the alarms themselves. Alarm fatigue may lead them to turn down the alarm volume, adjust the settings in a way that is unsafe for patients, or turn it off altogether, Dr. McKee said.

"After a while, alarms turn into white noise," Dr. McKee said. "A clinician can fail to respond because he doesn't hear it anymore or turn down the alarm because it's annoying."

That, she said, can be incredibly dangerous.

Between January 2005 and June 2010, the US Food and Drug Administration's Manufacturer and User Facility Device Experience database listed 566 alarm-related deaths, a number believed to underrepresent the true rate, the Joint Commission report states. Likewise, from January 2009 to June 2012, 98 alarm-related adverse medical events were reported to the commission. Again, the true number is believed to be higher. Of those 98 events, 80 people died, 13 suffered permanent loss of function, and 5 required extra care or an extended stay. Falls, delays in treatment, ventilator use, and medication errors were listed as causes of death or common injuries related to alarms. Main contributing factors included absent or inadequate alarm systems, improper alarm settings, and alarm signals that are not audible in all areas.

Key recommendations in the commission's report included establishing a cross-disciplinary team to address the potential effect of alarm fatigue in all patient care areas, creating priorities for the adoption of alarm technology, and training clinical care teams on safe alarm management and response in high-risk areas and on safe use of the devices.

To reduce nuisance alarms, single-use sensors on electrocardiography leads, for instance, should be changed according to the manufacturers' guides. In addition, hospitals and other healthcare facilities need to assess whether critical alarm signals can be easily heard in patient care areas.

"The issue is a critically important one," said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. Foster praised the recommendations and suggested healthcare organizations should adopt them. But, she added, they do not go far enough to address the root cause of alarm fatigue.

Foster sees the issue primarily as an engineering one. She said the healthcare industry should sit down with medical device makers to standardize the alarm systems. Different warning mechanisms, such as lights, sirens, and buzzers, should be created to differentiate between true emergencies and issues that can wait. If the airplane industry is able to do this for cockpit warning systems, she said, there is no reason that the medical industry should not take similar steps.

"Agreement that certain types of alarm will have certain types of meaning will have an incredible impact in increasing patient safety and well-being," she said.

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