Joint Commission outlines dangers of alarm fatigue

The Joint Commission this week issued a warning that healthcare workers can become numb to the incessant beeping of medical devices, creating life-threatening situations for patients.

The hospital accreditation body based the warning on events reported to its Sentinel Event database, which tracks serious safety-related events, though it has been sounding the alarm on this issue for years.

Indeed, "alarm fatigue"--when workers tune out alarms that just create more workplace noise--again topped the ECRI Institute's 2013 list of health technology hazards.

In January, The Joint Commission proposed making alarm management a national safety goal for 2014. That designation would require hospital leaders to set alarm management as a priority, establish a formal policy and provide training for staff. They would have to take inventory of alarms and identify their default settings as they set priorities for those to manage.

This week's warning notes that workers can be subjected to tens of thousands of beeps a day, adding that "between 85 and 99 percent of alarm signals do not require clinical intervention, such as when alarm conditions are set too tight; default settings are not adjusted for the individual patient or for the patient population; ECG electrodes have dried out; or sensors are mispositioned. …

"In response to this constant barrage of noise, clinicians may turn down the volume of the alarm setting, turn it off, or adjust the alarm settings outside the limits that are safe and appropriate for the patient--all of which can have serious, often fatal, consequences," it says.

Between January 2009 and June 2012, 80 alarm-related deaths and 13 serious alarm-related injuries were reported to The Joint Commission. Reporting is not required, so the number of injuries and deaths probably is higher, the warning states.

It points to the death of a 60-year-old man at the University of Massachusetts Memorial Medical Center in August 2010 that was featured in a Boston Globe article. A 2011 Globe investigation found at least 216 deaths nationwide from January 2005 to June 2010 linked to alarms on patient monitors, many attributed to worker desensitization to the noise. The newspaper's investigation was based on reports to a U.S. Food and Drug Administration database covering problems involving medical devices, according to a more recent Globe story.

The FDA's database lists more than 500 deaths potentially linked with hospital alarms, but those include reports of equipment malfunctions, not necessarily staff not reacting with urgency to the alarms, according to the Associated Press.

A year ago, The Joint Commission and the FDA announced efforts to combat alarm fatigue. The Joint Commission was to focus on worker training, while the FDA planned to survey roughly 4,500 hospitals and 1,000 long-term care facilities to get a better understanding of the problem.

To learn more:
- here's the warning (.pdf)
- check out the Boston Globe story
- read the Associated Press article

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