Growing Alarm over Alarm Fatigue in Hospitals

March 30, 2011

The FDA cautions hospital personnel on the dangers of turning off alarms on monitoring devices.

The FDA cautions hospital personnel on the dangers of turning off alarms on monitoring devices.

Back in January 2011, the FDA issued the following safety alert on preventing medical errors as part its “FDA Patient Safety News” program.

From 2005 through 2008, FDA received 566 reports of patient deaths related to the alarms on monitoring devices. Part of the problem is that alarms can very easily be disabled or silenced. Also, it is easy to overlook onscreen symbols indicating that an important alarm feature is not turned on or available. In many of the FDA reports, users were not familiar with how the monitoring equipment worked, or hadn't checked the monitor's alarm status.

In one case, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor sounding or displaying an alarm. It turned out that although the monitor detected the problem, its dysrhythmia processing had been turned off.

And in another case, an infant died when staff members did not notice a visual alarm on the screen of the perinatal monitor, warning that the child's heart rate was outside the defined parameters. The equipment had not been set up to provide audible alarms.

Here are some of the things FDA recommends to avoid alarm-related patient injuries and fatalities:

  • Do not silence alarms without first checking on the patient.
  • Make sure that all patient alarms are appropriately activated and not suspended, that dysrhythmia detection functions are available and appropriately activated, and that the alarm volume is high enough to be heard outside the patient's room. Perform these checks when assuming care of patients from colleagues, after shift changes, and after patients are transferred.
  • Become familiar with all monitor functions, especially dysrhythmia alarms and icons on the screen, and the meanings of various alarm sounds.
  • Make sure that new staff members, including travel and float nurses, are adequately trained on the unit's monitors before they care for patients.

The FDA also released the following video and sent it to 4,500 hospitals and nursing homes