Sounding the Alarm on Alarm Fatigue

by Gina Pugliese (Vice President, Premier Safety Institute)

(Editor’s note: Gina Pugliese recently joined the Physician-Patient Alliance for Health & Safety advisory board. We are pleased and honored to have her expertise and counsel.)

Alarms are a serious matter in busy hospitals and ERs.

Think about all of the devices used in patient care – infusion pumps, cardiac monitors, pulse oximetry devices, blood pressure monitors, bedside telemetry and ventilators. All of these devices have alarms. Collectively, the devices in use on a single patient can produce hundreds of alarms every day. Some alarms are inconsequential. Some are malfunctions. Others signal impending crisis. Many are simply not heard.

The Institute for Safe Medication Practices recently highlighted a case of a 17-year-old girl who died after a simple tonsillectomy done in an outpatient ambulatory surgery center. After the surgery, she was given a painkiller that slowed down her breathing. The drug led to respiratory depression and a fatal respiratory arrest.

Factors contributing to this tragedy included an obstructed view of the patient (a curtain had been drawn around the patient, obstructing the view necessary for the nurses to maintain an ongoing visual assessment) and a muted alarm on her monitoring equipment that couldn’t warn her nurse who was attending to another patient.

How could this happen?

First, consider the sheer number of devices with alarms.

A single patient can set off several hundred alarms each day, depending on the severity of their condition. Multiply that by the number of patients on any given day in a large hospital.

The Physician-Patient Alliance for Health & Safety found that 95% of hospitals surveyed are worried about the effects of alarm fatigue. And while 34% thought the problem is extremely difficult to solve, 61% didn’t think the problem is insurmountable.

INFOGRAPHIC: First National Survey of Patient-Controlled Analgesia Practices

The U.S. Food and Drug Administration (FDA) found that from 2005-2006, 566 alarm-related patient deaths were reported. However, the Joint Commission reported that these alarm-related events greatly under-represent the actual number of incidents.

Originally named by practitioners and researchers, alarm fatigue has gotten the attention of independent medical device evaluators. And the ECRI Institute has placed alarms at the top of its list of the top 10 health technology hazards for the last two years. It’s even become a National Patient Safety Goal by the Joint Commission effective January 1, 2014.

Hospitals have just 2 years to put new clinical alarm policies in place. Essentially, this includes any medical devices that have visual and/or auditory alarms. Exempt are things like CPOE alerts, nurse call systems and other kinds of IT gadgets.

Last April, the Joint Commission issued a Sentinel Event Alert, advising hospitals to do things like prepare an inventory of alarm-equipped medical devices and tailor alarm settings and limits for individual patients.

Addressing clinical alarm hazards is not so easy

According to the Joint Commission, as few as 1% of all alarm signals even require clinical intervention. These “false alarms” are things such as when alarm parameters are set too tight, default settings are never adjusted for the specific patient or population, ECG electrodes have dried out or sensors have dislodged. Some devices just alarm when they are working well.

Staff are often overwhelmed by all the noise and can’t distinguish among the sounding alarms. They become desensitized. And in their haste to regain sanity, may set alarm thresholds too high or too low, turn alarm volumes down or off, or miss an important alarm because the sounds just cease to be distinct in their minds. This is alarm fatigue.

In some instances:

  • Doors may be closed that make it hard to hear alarm signals
  • Alarms may be muted to help the patient rest
  • When the alarm does sound there may not be a clear assignment of responsibility about who should respond
  • Staff may hear the alarm but only after a significant amount of precious time has elapsed
  • A series of cascading “minor” alarm failures are the culprit

By the time an alarm signals a truly critical event, it could be too late.

Managing all of this noise is an overwhelming task. But don’t worry, my post tomorrow will provide you with the 10 tips to reduce alarm fatigue.

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