Time to Battle Alarm Fatigue

Better Monitoring and Management

Laura A. Stokowski, RN, MS

Disclosures

February 20, 2014

In This Article

Alarm-Related Harms

Evidence supports the commonsense conclusion that excessive alarms in patient care are distracting and interfere with the ability of nurses to perform critical patient care tasks.[6,7] The natural human adaptive response to a high rate of false alarms is to mistrust them, and to respond less often or react with less urgency.[7] It is not laziness or neglect that prevents nurses from responding to alarms. It is habituation to the noise, and a belief that the alarm, if it is heard at all, is almost certainly meaningless. A recent modest observational study documented a mere 47% response rate to cardiac monitor alarms, meaning that nurses failed to respond at all to more than one half of the alarms that occurred during the observation period.[6] This number might seem low, but in fact, none of the alarms that occurred during that time were true, clinically important alarms.

The heavy burden of nuisance alarms has the unfortunate effect of diminishing the value of physiologic monitoring in the eyes of nurses. Monitoring is just another chore that requires time and attention, instead of being a tool that helps nurses stay abreast of patient condition.[6] Rather than creating a safer environment, monitoring can have the opposite effect.

Alarm hazards aren't benign -- they have resulted in serious patient harm and death. A lawsuit charging that a patient's death was the result of "alarm fatigue" was settled in 2011.[8] From 2009 to 2012, the Joint Commission's Sentinel Event database received 98 reports of alarm-related events, 80 of which resulted in patient death and 13 in permanent loss of function.[9] Many incidents were the result of alarm mismanagement, such as absent or inadequate alarms systems, improper alarm settings, alarms that were inaudible to staff, and alarms that had been inactivated. From 2005 to 2008, the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database received 566 reports of patient deaths related to monitoring device alarms.[10] Alarm fatigue is the most common root cause of such hazards, but other identified factors include:

Alarm settings not customized to the individual patient or patient population;

Inadequate staff training on the proper use of medical device alarms;

Inadequate staffing to respond to alarms;

Alarm conditions and settings that are not integrated with other devices; and

Equipment malfunction and failures.

Nurses acknowledge that their lack of concern and slow response to low-priority alarms (such as leads-off alarms) could be dangerous, because a patient might have a life-threatening event while the leads are not functional. They also admit to occasionally taking inappropriate actions, such as lowering alarm volumes or disabling alarms when nuisance alarms become overwhelming.[6]

However, for the most part, high-priority, crisis-level alarms are not being missed or neglected, as Cvach clarifies. "It is the medium- and low-priority alarms that can precede the critical alarms that are being missed. If you can get to those, you may be able to avoid a critical alarm. Then there are the false alarms. The monitors in use today have a high false-alarm rate, because they err on the side of calling something real when it's not. The nurse looks at the monitor and sees that it is reading asystole or ventricular tachycardia, when a QRS and P-wave are clearly visible. When this happens often enough, the nurse starts to think everything is a false alarm."

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