Tuesday, April 9, 2013

The Joint Commission Warns of Alarm Fatigue

Medical alarms are meant to alert caregivers and healthcare providers to patient problems so that they can be solved. This isn’t always the case, however, according to an alert issued on Monday by the Joint Commission.  This “alarm fatigue,” as it is being called, poses a serious health risk to patients and the Joint Commission is urging hospital personnel to take a look at the issue.

The constant beeping of multiple devices, on multiple patients, at the same time, could lead to staff desensitization to the alarms, turning them into just background noise. If a staff member does acknowledge the alarms, may disable the beeping for the future, or miss some warnings that are difficult to hear when there are other alarms going off. According to the Food and Drug Administration (FDA) database, there have been over 560 patient alarm-related deaths over the past four years. The Joint Commission database includes 80 fatalities and 13 serious injuries related to alarms over a similar time period.

To help with this issue, the Joint Commission, along with the Association for the Advancement of Medical Instrumentation (AAMI) and the ECRI Institute, recommend that organizations:
·         Ensure that there is a process for safe alarm management and response in areas identified by the organization as high risk.
·         Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and the limits appropriate for each care area.
·         Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions; include identification of situations when alarm signals are not clinically necessary.
·         Establish guidelines for tailoring alarm settings and limits for individual patients. The guidelines should address situations when limits can be modified to minimize alarm signals and the extent to which alarms can be modified to minimize alarm signals.
·         Inspect, check and maintain alarm-equipped medical devices to provide for accurate and appropriate alarm settings, proper operation, and detectability. Base the frequency of these activities on criteria such as manufacturers’ recommendations, risk levels and current experience.

The Joint Commission also recommends staff training, and is considering creating a National Patient Safety Goal to address the issue. The Joint Commission Alert can be found here

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