TJC Suggests Steps for Combating Alarm Fatigue
Medical device alarm signals are vital for ensuring patient safety. However, the constant noise from these signals has led to alarm fatigue among healthcare providers, jeopardizing the health of patients. To combat this fatigue, The Joint Commission (TJC) has issued a Sentinel Event Alert with such recommendations as preparing an inventory of alarm-equipped medical devices and tailoring alarm settings and limits for individual patients.
Each day, there are tens of thousands of alarm signals throughout a healthcare facility. However, roughly 85 to 99% of these signals do not require clinical intervention. In addition, healthcare professionals learn to “block out” the cacophony of noise from their audio senses, risking missed alarm signals that do require immediate attention. Without an affirmative organizational plan, overwhelmed healthcare professionals sometimes reduce alarm noise in hospital units, by lowering signal volume levels on devices, turning signals off, or adjusting a device’s alarm parameters so that deteriorating patient conditions are not detected in a timely way. These actions can have serious or fatal consequences.
Between January 2009 and June 2012, TJC’s sentinel event database included reports of 98 alarm signal-related events. Of these events, 80 resulted in death, while 13 led to some type of permanent functional harm to patients. Five of the events resulted in extended patient care. A U.S. Food and Drug Administration database painted an even more disturbing picture, with reports of 560 alarm-related deaths during the same timeframe.
To prevent these adverse patient outcomes, TJC advises that facilities take the following actions, which correspond with recommendations made by the AAMI Foundation’s Healthcare Technology Safety Institute and ECRI Institute:
- Ensure there is a process for safe alarm management and response in high-risk areas
- Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk conditions and identify appropriate default settings
- Establish guidelines for alarm settings on devices used in high-risk areas and identify when alarm signals are not clinically necessary
- Create guidelines for tailoring alarm setting for individual patients and address situations when limits can be altered to minimize alarm signals
- Inspect, check, and maintain medical devices to provide for accurate and appropriate alarm settings, proper operation, and detectability
The alert also recommends that all clinical care team members receive training and education on alarm management and response in high-risk areas. Healthcare facilities also should look to reduce nuisance alarm signals and ensure that critical signals are audible in patient care areas.
The alert marks another step in TJC’s attempts to reduce alarm fatigue. In February, the commission invited interested parties to comment on a proposed National Patient Safety Goal, which included the following stated elements:
- Establish alarm safety as a priority
- Prepare an annual inventory of alarms and identify default settings
- Identify the most important alarms to manage
- Establish policies for managing the alarms
- Educate staff about alarm policies and procedures
TJC has said it is reviewing feedback it received in response. This feedback includes comments from the AAMI Foundation’s Healthcare Technology Safety Institute (HTSI), recommending that institutions maintain an alarm systems committee that would report to a patient safety executive. That executive would provide guidance for alarm system management.
In October 2011, the AAMI Medical Device Alarm Summit was co-convened with the FDA, TJC, ECRI Institute, and the American College of Clinical Engineering. At the event, 300 stakeholders developed priorities on the key issues with the safety and effectiveness of alarm systems. To read the report on the summit, please click here.
Since that event was held, HTSI has initiated a number of important initiatives related to improving patient safety with alarm management (click here to learn more). HTSI also has a number of additional projects planned to help support the healthcare community with this complex issue. In addition, AAMI has developed a “hot topic” page on this issue, which is available here.
To read TJC’s alert, please click here.
Posted: April 8, 2013