Joint Commission Issues Alert on ‘Alarm Fatigue’

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The Joint Commission has warned health care providers that they can quickly become desensitized to patient alarms because so many occur. But ignoring these alarms can have fatal consequences for patients, the Joint Commission warned. Citing hospital data between January 2009 and June 2012, the commission's Sentinel Event Alert database recorded 98 alarm-related adverse events, 80 of which resulted in death. Another 13 resulted in permanent loss of function and 5 led to unexpected additional care or an extended stay in the hospital. The analysis found that inadequate alarms, improper settings, and signals that were not loud enough all contributed to the reported adverse events. Alarms that were improperly turned off also were a problem. The Joint Commission recommended several steps to curb “alarm fatigue.” ▸Set up a process for alarm management and response, especially in high-risk areas.▸Perform an inventory of all devices with alarms in high-risk areas and their default settings.▸Establish guidelines for alarm settings in high-risk areas and for high-risk conditions.▸Establish guidelines for tailoring alarm settings to individual patients.▸Inspect and maintain devices. “Alarm fatigue and management of alarms are important safety issues that we must confront,” Dr. Ana McKee, executive vice president and chief medical officer at the Joint Commission, said in a statement. The alert also calls on organizations to provide training and education on safe alarm management and response to all members of the care team.