Recommendations to Reduce Alarm Fatigue Issued by Joint Commission

The Joint Commission recently issued important recommendations to tackle the problem of medical device "alarm fatigue" in hospitals and its associated safety concerns.

The Joint Commission recently issued important recommendations to tackle the problem of medical device "alarm fatigue" in hospitals and its associated safety concerns.1 Alarm-equipped devices are essential to providing safe care to patients in many health care settings, and clinicians depend upon them for information. However, these devices also present many challenges for health care practitioners when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.

The Joint Commission Alert noted that medical devices for each hospital patient can generate as many as several hundred alarm signals per day on one hospital unit, “translating into thousands of alarm signals on every unit and tens of thousands of alarm signals throughout the hospital every day.” It is estimated that 85% to 99% of alarm signals do not require clinical intervention, and thus clinicians become desensitized or immune to the sounds and are overwhelmed by all the information (“alarm fatigue”).

In response to the continuous noise of alarms, clinicians may turn down the volume of the alarm, turn it off, or adjust the settings outside safe and appropriate limits--any of which can have potentially serious, or fatal, consequences.

The Joint Commission’s database includes reports of 98 alarm-related events between January 2009 and June 2012. Eighty resulted in death, 13 in permanent loss of function, and 5 in unexpected additional care or extended stay. The majority of reported events occurred in telemetry, intensive care, general medicine, and emergency departments. Main contributing factors included absent or inadequate alarm systems, improper alarm settings, and alarm signals that are not audible in all areas.

The main recommendations and potential strategies for improvement include:

  1. Leadership ensures a process for safe alarm management and response in high-risk areas
  2. Inventory made of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and limits.
  3. Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions; include identification of situations when alarm signals are not clinically necessary.
  4. Establish guidelines for tailoring alarm settings and limits for individual patients, which should address situations when limits can be modified to minimize alarm signals.
  5. Inspect, check, and maintain alarm-equipped devices to provide for accurate and appropriate alarm settings, proper operation, and detectability. Base frequency of these activities on manufacturers’ recommendations, risk levels, and current experience.

1. Joint Commission. Sentinel Event Alert Issue 50. Medical device alarm safety in hospitals. April 8, 2013. Available athttp://www.jointcommission.org/sea_issue_50.)