Alarm Fatigue

Two Resources on Alarm Safety from The Joint Commission and the ECRI Institute

by Sean Power

When The Joint Commission released its Sentinel Event Alert 50 on medical device alarm safety in hospitals it produced an infographic about the issue. The infographic summarizes the scope of the problem, shares data about reported alarm safety events, and offers recommendations to address the issue. The ECRI Institute also has a poster on alarm safety with recommendations for improving alarm management.

Let’s take a look at both resources.

1. The Joint Commission infographic on medical device alarm safety in hospitals

The Joint Commission's infographic on medical device alarm safety.

Some key facts from the infographic:

  1. Tens of thousands of alarm signals occur throughout a hospital per day.
  2. Eighty-five to ninety-nine percent of alarm signals don’t require clinical intervention.
  3. Ninety-eight alarm-related events were (voluntarily) reported form January 2009 to June 2012.
  4. Eighty of these events resulted in death. Thirteen in permanent loss of function and five in additional care or extended stay.

The infographic highlights the need for more attention to best practices.

The Physician-Patient Alliance has published some tips from experts who have researched the topic. See this article on technology recommendations to reduce alarm fatigue from Patient Safety & Quality Healthcare and this article reprinted from Hospitalist News and Internal Medicine News on the same topic. Still, more discussion is needed.

2. The ECRI Institute’s Strategies to Improve Alarm Safety poster

ECRI Institute's Strategies to Improve Alarm Safety poster.

The ECRI Institute captures the complexity of alarm management. To tackle the issue, the ECRI Institute suggests hospitals take the following six steps:

  1. Assemble a multidisciplinary team. This team needs to include all stakeholders including an administrative sponsor, key medical staff, nurse managers, frontline nurses, monitor technicians, patient safety/risk managers, clinical engineering staff, and IT staff, among others. This team carries out the next five steps.
  2. Review recent events and near misses. Examine root causes and the frequency of alarm types. Look for trends and patterns in the data.
  3. Observe alarm coverage processes and ask nurses and other staff about their concerns. Map processes for alarm notification and response. Identify obvious problems and excessive alarms.
  4. Review the entire alarm coverage system. This step includes looking at hospital culture, infrastructure, practices, and technology to identify any overarching themes or areas for improvement.
  5. Identify patient safety vulnerabilities and potential failures. The ECRI poster has a short list of failures and causes worth reading.
  6. Develop realistic, implementable strategies to address underlying causes. Create a road map of fixes that can be implemented immediately and in the future.

The ECRI Institute’s poster demonstrates the degree to which alarm safety affects everyone in the hospital. The multidisciplinary team consists of stakeholders with diverse skill sets and broad expertise.

The Physician-Patient Alliance would add to this list of stakeholders the patients themselves. Educating patients and their families why they must be monitored, what monitor readouts mean, and what to do when alarms sound, can go a long way in reducing alarm fatigue.

What recommendations would you offer to hospitals tackling alarm fatigue?

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