Joint Commission Issues Alert on Medical Device Alarm Fatigue

The Joint Commission on April 8 issued a Sentinel Event Alert to hospitals, imploring leaders to take a focused look at the serious risk caused by “alarm fatigue” from medical devices.

“These alarm-equipped devices are essential to providing safe care to patients in many health care settings; clinicians depend on these devices for information they need to deliver appropriate care and to guide treatment decisions,” according to the Joint Commission message. “However, these devices present a multitude of challenges and opportunities for health care organizations 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 commission acknowledges that alarms can sound several hundred times a day in a unit, and could total tens of thousands in a day throughout a hospital, with the vast majority not requiring clinical intervention. Alarm conditions may be set to tight, default settings are not adjusted for the patient or patient population, ECG electrodes may dry out or sensors may be mis-positioned, among other reasons for these alarms. Consequently, clinicians may become immune to the sounds, or turn down the volume, adjust settings outside safe limits or turn the alarm off, according to the commission.

The Sentinel Event Alert recommends strategies for improving safety related to medical device alarms, and notes that the Joint Commission may develop a related National Patient Safety Goal. Text of the alert is available here.