Patient Safety / Quality

Do you hear what I hear? Combating alarm fatigue

As you enter your unit to begin your shift, a cacophony of alarms from multiple devices greets you. The cacophony continues throughout your entire shift.

Various devices, including beds, infusion pumps, cardiac monitors, ventilators, mechanical vital-sign machines, sequential compression stockings, and many others, have audible alarms competing for caregivers’ attention. Unless managed properly, alarms meant to alert clinicians to problems that require action may put patients at risk.

Many alarms are false; an estimated that 85% to 95% require no intervention. As a result, caregivers have become desensitized—a phenomenon called alarm fatigue—and simply ignore the alarms. But not all alarms are false, and assuming they’re false can lead to dangerous delays in response. Alarm fatigue has become such a widespread critical problem that The Joint Commission (TJC) issued a sentinel event alert on alarms in April 2013 and made alarm management a National Patient Safety Goal starting in 2014.

Causes and contributing factors

In its sentinel event alert, TJC identified several factors that contribute to alarm fatigue:

  • alarm parameter thresholds set too tight
  • alarm settings not adjusted to the individual patient
  • poor electrocardiogram (ECG) electrode practices resulting in frequent false signals
  • inability of staff to hear alarms or detect where an alarm is coming from
  • inadequate staff training on monitors and alarms
  • inadequate staff response to alarms
  • malfunctioning alarms.

Why alarms are the leading health-device technology hazard

ECRI Institute, a nonprofit organization that researches best approaches to improving patient care, lists alarm hazards as the top health-device technology hazard. According to TJC’s database, hospitals reported 80 deaths and 13 severe injuries attributed to alarm hazards from January 2009 to June 2012. Investigations into these incidents determined a clear connection to a device alarm. The Food and Drug Administration (FDA) reported more than 560 alarm-related deaths between 2005 and 2008. (See the box below.)

Death despite alarms

The case that brought alarm fatigue to the forefront occurred in a Boston hospital. A patient being treated for a head injury was on a cardiac monitor and pulse oximetry. Because he’d been restless, he was receiving an antianxiety drug. According to reports, alarms sounded indicating an increased heart rate and reduced oxygenation 1 hour before the nurse discovered he was unresponsive. (He eventually died.) An investigation found the alarm volume had been turned off.

Recommendations

At first glance, it may be easy to blame bedside caregivers for not responding to alarms. But alarm fatigue is systemic and needs to be addressed at the facility level, with a commitment from many disciplines, including biomedical engineering, physicians, and information technology. Along with TJC, the ECRI Institute and the Association for the Advancement of Medical Instrumentation have issued several recommendations in an effort to combat alarm fatigue.


  • Put an alarm-management process in place.
  • Review and adjust default parameter settings and ensure appropriate settings for different clinical areas.
  • Determine where and when alarms aren’t clinically significant and may not be needed.
  • Create procedures that allow staff to customize alarms based on the individual patient’s condition.
  • Make sure all equipment is maintained properly.

Other recommendations include verifying that all staff members who use alarmed devices are properly trained in safe alarm management. Also, bedside caregivers should frequently change single-use sensors, such as pulse oximetry sensors and ECG electrodes, which may dry out after 24 hours. To reduce alarms caused by artifact, caregivers should make sure the patient’s skin has been prepared properly before applying electrodes.

Also, to help decrease alarms, the preset delay of a pulse oximetry monitor should be adjusted (for instance, from 5 seconds to 10 seconds) so the alarm doesn’t sound unless the patient sustains a continuous drop in oxygenation for 10 seconds. This would eliminate alarms caused by movement and transient oxygenation changes. Johns Hopkins Hospital reduced pulse oximetry alarms by 63% by decreasing the low threshold limit from 90% to 88%.

Creating an alarm committee
Ideally, facilities should form an interdisciplinary committee to address alarm issues. A good starting point is to collect data on the number and severity of alarms and the response time to them. ECRI recommends examining recent alarm events and near misses. The committee would examine the data for frequency of alarm types, aggregation of alarm types for care area or shift, and trends. Staff members would provide information on current processes for responding to different alarm levels and the barriers they face in alarm response, such as excessive nuisance alarms, competing priorities, and diffuse responsibility for alarm response.

Combating alarm fatigue

Facilities should put measures in place to delineate responsibility for alarms, including a backup plan with coverage tiers or use of two-way communication devices that allow caregivers to request help if they can’t respond to an alarm. Another way to reduce alarms is to ensure appropriate patient monitoring. Protocols can be developed to determine which types of patients are monitored by which devices, to make sure alarms are actionable. Once a decision is made to monitor a patient, alarm parameters should be individualized based on the patient’s condition and baseline data.

The medical device industry can help combat alarm fatigue by developing multiparameter alarm filtering, so that only valid alarms are passed on to caregivers. Also, the FDA is committed to looking at devices with a more critical eye before approving them, including monitors that measure multiple functions.

Striving for a holistic solution

Alarm fatigue is a system-wide challenge that needs to be approached holistically. A multidisciplinary committee can bring multiple perspectives on which to base a comprehensive plan that’s individualized to the facility. The committee can develop policies and procedures, as well as a program that focuses on making adjustments to minimize false alarms and prevent missing true alarms. The time caregivers save by not having to respond to false alarms is time they can use caring for patients instead of tending to machines.

Peggy A. Ensslin is a nurse educator at the Orange Regional Medical Center in Middletown, New York.

Selected references
Citing reports of alarm related deaths, the Joint Commission issues a sentinel event alert for hospitals to improve medical device alarm safety. ED Manag. 2013;26(6); suppl 1-3.

Clark T. Closing the clinical alarm gap. 24×7 Mag. September 15, 2010. www.24x7mag.com/2010/09/closing-the-clinical-alarm-gap. Accessed September 24, 2014.

ECRI Institute. Strategies to improve monitor alarm safety. 2011. https://www.ecri.org/Resources/Whitepapers_and_reports/Monitor_Alarm_Safety_Poster_Presentation.pdf Accessed September 24, 2014.

ECRI Institute. Top 10 health technology hazards for 2014. Health Devices. 2013;42(11):354-80.

FDA, the Joint Commission aim to reduce alarm fatigue. AACN Bold Voices. 2012;4(8):9. www.nxtbook.com/nxtbooks/aacn/boldvoices_201208/?startid=0. Accessed September 24, 2014.

Graham KC, Cvach M. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. Am J Cri Care. 2010;19(1):28-34.

Joint Commission Alert: Device alarms should not be ignored. Healthcare Purchas News. 2013;37(5):6. http://connection.ebscohost.com/c/articles/87396864/joint-commission-alert-device-alarms-should-not-be-ignored. Accessed September 24, 2014.

Kowalczyk L. Alarm fatigue a factor in second death. Boston Globe. September 21, 2011.
www.bostonglobe.com/2011/09/20/umass/qSOhm8dYmmaq4uTHZb7FNM/story.html. Accessed September 24, 2014.

McKinney M. Alarm fatigue sets off bells; Mass. incident highlights need for protocols check. Modern Healthc. 2010;40(15):14. www.modernhealthcare.com/article/20100412/MAGAZINE/100409955. Accessed September 24, 2014.

Sendelbach S, Jepsen S. AACN Practice Alert: Alarm management. April 2013. www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf. Accessed September 24, 2014.

TJC warns about alarm fatigue putting patients at risk. Healthc Risk Manag. 2013;35(6):68. http://connection.ebscohost.com/c/articles/87596459/tjc-warns-about-alarm-fatigue-putting-patients-risk. Accessed September 24, 2014.

The Joint Commission. Sentinel Event Alert. Medical device alarm safety in hospitals.
Issue 50. April 8, 2013. http://www.jointcommission.org/assets/1/18/sea_50_alarms_4_5_13_final1.pdf. Accessed September 24, 2014.

Welch J. An evidence-based approach to reduce nuisance alarms and alarm fatigue. Biomed Instrum Technol. 2011;Spring;Suppl:46-52.

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