The Newsletter for SUNY Downstate
University Hospital of Brooklyn
Alarm Fatigue and Patient Safety
By Dianne Forbes Woods, RN, MA, NE-BC
Deputy Nursing Director
Walking onto a patient care unit in a hospital today is anything but a quiet experience. Infusion pumps, ventilators, and ECG monitors are just a few of the types of medical devices attached to patients delivering therapies and providing clinical information.
These alarm-equipped devices are essential to providing safe care to patients; nurses and doctors depend on them for information needed to guide treatment decisions.
However, as The Joint Commission noted in its recent Sentinel Event Alert (Medical Device Alarm Safety, April 8, 2013) these devices present a multitude of challenges when their alarms create similar sounds; when their default settings are not changed; and when there is a failure to respond to their alarm signals.
The number of alarm signals per patient per day can reach several hundred depending on the unit, translating to thousands of alarm signals throughout the hospital every day.
The Joint Commission's national Sentinel Event database includes reports of 98 alarm-related events between January 2009 and June 2012, with 80 resulting in death, 13 in permanent loss of function, and five in unexpected additional care or extended stay.
Major contributing factors include:
- Absent or inadequate alarm system (30)
- Improper alarm settings (21)
- Alarm signals not audible in all areas (25)
- Alarm signals turned off (36)
Another major contributing factor is "Alarm Fatigue." Alarm fatigue can develop when a person is exposed to an excessive number of alarms.
Strategies to Combat Alarm Fatigue
In June, The Joint Commission, which accredits hospitals, directed facilities to make alarm safety a top priority. Starting in January 2014, hospitals must identify the alarms that pose the biggest safety risks by unnecessarily adding noise or being ignored.
Here are some action strategies suggested by the American Association of Critical Care Nurses and other organizations:
- Provide proper skin preparation for ECG electrodes and change them daily (this reduces false alarms from poor connections).
- Customize alarm parameters and levels on devices (Individualizing parameters reduces the number of alarms not requiring intervention.)
- Provide ongoing education to all staff on alarm awareness and alarm fatigue.
- All employees, from housekeepers to administrators, who pass by a patient's room should stop if they hear an alarm. They need to make sure the patient is breathing and call for help if necessary.
This situation can result in sensory overload, and can cause a practitioner to become desensitized to the alarms. Consequently, the response may be delayed, or alarms may be missed altogether.
Although studies show it is difficult for humans to differentiate among more than six different alarm sounds, the average number of alarms in an ICU has increased from 6 in 1983 to more than 40 different alarms in 2011.
As noted in a July 7, 2013 Washington Post article ("Too Much Noise from Hospital Alarms Poses Risk for Patients") clinicians and patient-safety advocates have warned of alarm fatigue for years, but the issue is taking on greater urgency as hospitals invest in more complex, often noisy devices meant to save lives.
This "alarming" issue needs the full support of healthcare leadership, clinicians, researchers, and manufacturers to ensure patient safety.