The national organization that accredits hospitals warned Monday that the constant beeping of alarms on patient monitors desensitizes caregivers, causing them to ignore or even disable the sounds that signal that patients may be in danger.
The Joint Commission issued a “sentinel event alert” to hospitals, saying the problem of “alarm fatigue” can jeopardize patients, and the commission urged hospitals “to take a focused look at this serious patient safety issue.’’
Between January 2009 and June 2012, the commission received reports of 80 alarm-
related deaths and 13 serious alarm-related injuries. Hospitals report these events voluntarily — they are not required to — so the numbers of deaths and injuries are probably far higher, the commission said.
The alert cites a Boston Globe article that detailed the death of a 60-year-old man at UMass Memorial Medical Center in August 2010, “not from the injury he suffered to his head from a fallen tree branch, but from a system failure that resulted in delayed response to an alarm signal that indicated significant changes in his condition.’’
A Globe investigation in 2011 identified at least 216 deaths nationwide from January 2005 to June 2010 linked to alarms on patient monitors that track heart function, breathing, and other vital signs. In many cases, medical workers did not react with urgency or did not notice the alarm, a type of desensitization that occurs from hearing alarms, many of them false, all day long.
The Globe based its numbers on an analysis of a US Food and Drug Administration database of problems involving medical devices. The FDA was able to identify 560 alarm-
related deaths in a recent four-year period.
The Joint Commission recommended Monday that hospitals take several steps, including making sure that settings are correct on medical devices used in high-risk areas and for high-risk conditions. It also recommends identifying situations in which alarms are not clinically necessary, tailoring alarm settings for individual patients, training caregivers on safe alarm management and response in high-risk areas, and reducing nuisance alarms.
Jim Keller, a vice president at ECRI Institute, a nonprofit research and consulting organization in Pennsylvania that specializes in medical devices, welcomed the alert but said more needs to be done, particularly in device design and caregiver response to alarms.
“The Joint Commission should be applauded for helping to raise awareness about alarm safety,’’ he said in e-mail. “We think the alert will contribute to moving toward a solution, as it will force hospitals to pay much closer attention to clinical alarm safety than ever before. But the alert alone isn’t enough to solve the problem.’’
The Massachusetts Hospital Association said that “the guidance from the Joint Commission will be reviewed by hospitals to help them maximize the effectiveness of their respective systems.”
The commission is working on a national patient safety goal on alarm management, which signals the issue is a priority hospitals must address to remain accredited. The goal, if approved this spring, would require hospitals to make improvements starting in January 2014.
A draft of the safety goal released by the Joint Commission would require hospitals to make alarm safety a priority and decide whether specific alarms are needed or unnecessarily contribute to safety concerns, when alarms can be disabled, and who has authority to decide on disabling alarms.