The national organization that accredits hospitals warned on Monday that the constant beeping of alarms on patient monitors desensitizes caregivers, causing them to ignore or even disable the sounds that signal patients may be in danger.
The Joint Commission issued a “sentinel event alert” to hospitals, saying that the problem of “alarm fatigue” can jeopardize patients, and it urged hospitals “to take a focused look at this serious patient safety issue.’’
Between January 2009 and June 2012, the group received reports of 80 alarm-related deaths and 13 serious alarm-related injuries. Hospitals report these events voluntarily—they are not required to—so the numbers of deaths and injuries are likely far higher, the commission said.
The alert cites a Boston Globe article that detailed the death of a 60-year-old man at UMass Memorial Medical Center in August 2010, “not from the injury he suffered to his head from a fallen tree branch—but from a system failure that resulted in delayed response to an alarm signal that indicated significant changes in his condition.’’
A Boston Globe investigation in 2011 identified at least 216 deaths nationwide between January 2005 and June 2010 linked to alarms on patient monitors that track heart function, breathing, and other vital signs. In many cases, medical personnel didn’t react with urgency or didn’t notice the alarm, a type of desensitization that occurs from hearing alarms—many of them false—all day long.
The Globe based its numbers on an analysis of a US Food and Drug Administration database of problems involving medical devices. The FDA was able to identify 560 alarm-related deaths in a recent four-year period.
The Joint Commission recommended that hospitals take several steps, including identifying alarm-equipped medical devices used in high-risk areas and for high-risk conditions, and deciding how they should be set; identifying situations when alarm signals are not clinically necessary; establishing guidelines for tailoring alarm settings and limits for individual patients; training caregivers on safe alarm management and response in high-risk areas; and considering how to reduce nuisance alarm signals.
The commission also is working on a national patient safety goal on alarm management, which signals the issue is a high priority that hospitals must address to remain accredited.