Health & wellness

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.

Advertisement

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.

Get The Weekender in your inbox:
The Globe's top picks for what to see and do each weekend, in Boston and beyond.
Thank you for signing up! Sign up for more newsletters here

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.

Advertisement

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 kowalczyk@globe.com.
Loading comments...
You're reading  1 of 5 free articles.
Get UNLIMITED access for only 99¢ per week Subscribe Now >
You're reading1 of 5 free articles.Keep scrolling to see more articles recomended for you Subscribe now
We hope you've enjoyed your 5 free articles.
Continue reading by subscribing to Globe.com for just 99¢.
 Already a member? Log in Home
Subscriber Log In

We hope you've enjoyed your 5 free articles'

Stay informed with unlimited access to Boston’s trusted news source.

  • High-quality journalism from the region’s largest newsroom
  • Convenient access across all of your devices
  • Today’s Headlines daily newsletter
  • Subscriber-only access to exclusive offers, events, contests, eBooks, and more
  • Less than 25¢ a week
Marketing image of BostonGlobe.com
Marketing image of BostonGlobe.com
Already a subscriber?
Your city. Your stories. Your Globe.
Yours FREE for two weeks.
Enjoy free unlimited access to Globe.com for the next two weeks.
Limited time only - No credit card required!
BostonGlobe.com complimentary digital access has been provided to you, without a subscription, for free starting today and ending in 14 days. After the free trial period, your free BostonGlobe.com digital access will stop immediately unless you sign up for BostonGlobe.com digital subscription. Current print and digital subscribers are not eligible for the free trial.
Thanks & Welcome to Globe.com
You now have unlimited access for the next two weeks.
BostonGlobe.com complimentary digital access has been provided to you, without a subscription, for free starting today and ending in 14 days. After the free trial period, your free BostonGlobe.com digital access will stop immediately unless you sign up for BostonGlobe.com digital subscription. Current print and digital subscribers are not eligible for the free trial.