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Joint Commission to hospitals: Tackle problem of alarm fatigue among staff

The national organization that accredits hospitals is proposing a new patient safety goal: hospitals must urgently tackle the failure of medical staff to respond to patient alarms, a common phenomenon known as alarm fatigue.

The Joint Commission previously, in 2004, made improving alarm safety part of its national patient safety goals, which signaled it was a top priority. However, the agency soon dropped the goal, thinking that hospitals had solved the problem.

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But a Boston Globe investigation in 2011 revealed that the problem was continuing. The Globe identified at least 216 deaths nationwide between January 2005 and June 2010 linked to the dozens of alarms on patient monitors, which track heart function, breathing, and other vital signs.

In many cases, medical personnel didn’t react with urgency or didn’t notice an alarm, a type of desensitization that occurs from hearing alarms — many of them false — all day long.

In one case, at UMass Memorial Medical Center in Worcester, nurses failed to respond to an alarm that sounded for about 75 minutes, signaling that a patient’s heart monitor battery needed to be replaced. The battery died, so when the patient’s heart then failed, no crisis alarm sounded. In another instance at Massachusetts General Hospital, an elderly man suffered a fatal heart attack while the crisis alarm on his cardiac monitor was turned off and staff did not respond to numerous lower-level alarms warning of a low heart rate.

Under the Joint Commission’s proposal, hospital leaders must make alarm safety a priority, conduct an inventory of alarms and decide which ones are unnecessary, and educate staff about the hospital’s alarm policies, as a condition of accreditation.

Hospitals have until Feb. 26 to comment on the proposal.

Here is the commission’s rationale:

Alarms are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety. This is a multi-faceted problem. In some situations, individual alarms are difficult to detect.

At the same time, many patient care areas have numerous alarms and the resulting noise tends to desensitize staff and cause them to ignore alarms or even disable them. Other issues associated with effective alarm management include too many devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow.

Liz Kowalczyk can be reached at
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