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April 9, 2013

Joint Commission issues Sentinel Alert on alarm fatigue

Daily Briefing

The Joint Commission on Monday issued a Sentinel Event Alert calling for the hospital industry to address "alarm fatigue," which can lead to patient injury or death.

When medical devices issue too many audio and visual alerts, health care providers can experience alarm fatigue, which often leads them to ignore or become desensitized to such alerts. From January 2009 to June 2012, the Joint Commission received reports of 80 alarm-related patient deaths and 13 serious alarm-related injuries.

The commission noted that the actual numbers of alarm-related deaths and injuries likely are much higher because hospitals are not required to report such events. The hospitals that do report alarm-related incidents do so voluntarily.

The Sentinel Event Alert states that although alarm-equipped devices are "essential to providing safe care to patients in many health care settings," they pose challenges when they "create similar sounds, when their default settings are not changed and when there is a failure to respond to their alarm signals."

Alarms can sound tens of thousands of times daily in a hospital and several hundred times daily in a specific hospital unit, but most alarms do not require clinical intervention, according to the commission.

The commission called for hospitals "to take a focused look at this serious patient safety issue." Specifically, the commission recommended that hospitals:

  • Decide how best to set alarms on devices used in high-risk areas and for high-risk conditions;
  • Establish guidelines on tailoring alarm settings to individual patients;
  • Identify situations in which alarm signals are not clinically needed;
  • Consider how to reduce unnecessary alarms; and
  • Teach caregivers about safe alarm management and response in high-risk areas (Kowalczyk, Boston Globe, 4/8; Goedert, Health Data Management, 4/8).
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