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A single hospitalized patient can generate up to several hundred alarm signals each day, causing physicians to quickly become desensitized to the noise. But ignoring these alarms can have fatal consequences for patients, the Joint Commission warns.
Between January 2009 and June 2012, the Joint Commission’s Sentinel Event Alert database recorded 98 alarm-related adverse events, 80 of which resulted in death. Another 13 resulted in permanent loss of function and 5 led to unexpected additional care or an extended stay in the hospital.
The Joint Commission found that inadequate alarms, improper settings, and signals that were not loud enough all contributed to the reported adverse events. Alarms that were improperly turned off also were a problem, according to the Joint Commission.
In the Sentinel Event Alert issued on April 8, the Joint Commission recommended several steps hospital leaders can take to curb the "alarm fatigue" common in hospitals.
– Set up a process for alarm management and response, especially in high-risk areas.
– Perform an inventory of all devices with alarms in high-risk areas and their default settings.
– Establish guidelines for alarm settings in high-risk areas and for high-risk conditions, including situations when alarms are not clinically necessary.
– Establish guidelines for tailoring alarm settings and limits for individual patients.
– Inspect and maintain alarm-equipped devices.
"Alarm fatigue and management of alarms are important safety issues that we must confront," Dr. Ana McKee, executive vice president and chief medical officer at the Joint Commission, said in a statement. "The recommendations in this alert offer hospitals a framework on which to assess their individual circumstances and develop a systematic, coordinated approach to alarms. By making alarm safety a priority, lives can be saved."
The Sentinel Event Alert also calls on hospitals to provide training and education on safe alarm management and response in high-risk areas to all members of the clinical care team.
In addition to the guidance to hospitals, the Joint Commission is considering the creation of a National Patient Safety Goal on the issue of alarm fatigue.
Twitter: @MaryEllenNY
A single hospitalized patient can generate up to several hundred alarm signals each day, causing physicians to quickly become desensitized to the noise. But ignoring these alarms can have fatal consequences for patients, the Joint Commission warns.
Between January 2009 and June 2012, the Joint Commission’s Sentinel Event Alert database recorded 98 alarm-related adverse events, 80 of which resulted in death. Another 13 resulted in permanent loss of function and 5 led to unexpected additional care or an extended stay in the hospital.
The Joint Commission found that inadequate alarms, improper settings, and signals that were not loud enough all contributed to the reported adverse events. Alarms that were improperly turned off also were a problem, according to the Joint Commission.
In the Sentinel Event Alert issued on April 8, the Joint Commission recommended several steps hospital leaders can take to curb the "alarm fatigue" common in hospitals.
– Set up a process for alarm management and response, especially in high-risk areas.
– Perform an inventory of all devices with alarms in high-risk areas and their default settings.
– Establish guidelines for alarm settings in high-risk areas and for high-risk conditions, including situations when alarms are not clinically necessary.
– Establish guidelines for tailoring alarm settings and limits for individual patients.
– Inspect and maintain alarm-equipped devices.
"Alarm fatigue and management of alarms are important safety issues that we must confront," Dr. Ana McKee, executive vice president and chief medical officer at the Joint Commission, said in a statement. "The recommendations in this alert offer hospitals a framework on which to assess their individual circumstances and develop a systematic, coordinated approach to alarms. By making alarm safety a priority, lives can be saved."
The Sentinel Event Alert also calls on hospitals to provide training and education on safe alarm management and response in high-risk areas to all members of the clinical care team.
In addition to the guidance to hospitals, the Joint Commission is considering the creation of a National Patient Safety Goal on the issue of alarm fatigue.
Twitter: @MaryEllenNY
A single hospitalized patient can generate up to several hundred alarm signals each day, causing physicians to quickly become desensitized to the noise. But ignoring these alarms can have fatal consequences for patients, the Joint Commission warns.
Between January 2009 and June 2012, the Joint Commission’s Sentinel Event Alert database recorded 98 alarm-related adverse events, 80 of which resulted in death. Another 13 resulted in permanent loss of function and 5 led to unexpected additional care or an extended stay in the hospital.
The Joint Commission found that inadequate alarms, improper settings, and signals that were not loud enough all contributed to the reported adverse events. Alarms that were improperly turned off also were a problem, according to the Joint Commission.
In the Sentinel Event Alert issued on April 8, the Joint Commission recommended several steps hospital leaders can take to curb the "alarm fatigue" common in hospitals.
– Set up a process for alarm management and response, especially in high-risk areas.
– Perform an inventory of all devices with alarms in high-risk areas and their default settings.
– Establish guidelines for alarm settings in high-risk areas and for high-risk conditions, including situations when alarms are not clinically necessary.
– Establish guidelines for tailoring alarm settings and limits for individual patients.
– Inspect and maintain alarm-equipped devices.
"Alarm fatigue and management of alarms are important safety issues that we must confront," Dr. Ana McKee, executive vice president and chief medical officer at the Joint Commission, said in a statement. "The recommendations in this alert offer hospitals a framework on which to assess their individual circumstances and develop a systematic, coordinated approach to alarms. By making alarm safety a priority, lives can be saved."
The Sentinel Event Alert also calls on hospitals to provide training and education on safe alarm management and response in high-risk areas to all members of the clinical care team.
In addition to the guidance to hospitals, the Joint Commission is considering the creation of a National Patient Safety Goal on the issue of alarm fatigue.
Twitter: @MaryEllenNY