The Deadly Alarm Fatigue Problem and You


The Deadly Alarm Fatigue Problem and You

When alarms are ignored -- or cry wolf -- patients may be in peril

By Sue Montgomery, RN, BSN, CHPN
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­The nonprofit ECRI Institute lists “alarm fatigue” as one of the leading technological hazards now facing hospitals. A single patient can generate hundreds of alarms and alerts in a single day. When alarms are ignored — or “cry wolf” — patients may be in peril.

As hospital technology grows, so too do the problems that go with it. We’re all familiar with the obnoxious chorus of pings, shrills, beeps and blares that tell you a patient may be in trouble. The problem is that the average critical care patient may generate hundreds of alarms in any given 24-hour period. That’s a lot of beeps and whistles to process for nurses already struggling with back-breaking, brain-busting workloads during any given shift.

To make matters worse, too many alarms are actually due to artifact, some non-critical issue or plain old malfunction. If a device cries wolf too many times, you might not respond quickly enough the one time the alarm is for real, setting you — and your patients — up for disaster.


In 2013, Barbara Drew, RN, Ph.D., FAAN, FAHA, a professor at UCSF School of Nursing, examined all the alarms that occurred at USCF Hospital over the course of one month. She found that a single patient could generate 1,000 or more alarms each day. The vast majority were technically false, but a few really did signal a life-threatening medical crisis.

With so many alarms, separating the critical from the trivial becomes an ongoing struggle. “You have to decide if it’s a bed alarm, a ventilator alarm or something else,” says Drew. “You have to make a decision about whether it’s a technical problem or something more serious, and then you have to decide if and how quickly to respond.”

Unfortunately, the consequence is that some alarm events that warrant a response don’t get one in time. In April 2013, The Joint Commission issued a sentinel event alert regarding medical device alarm safety after receiving 98 reports of alarm-related events that resulted in death or injury. Here’s just a sampling of alarm-related nightmares:

◗  A 77-year-old Massachusetts woman died of cardiac arrest in 2007 after her heart monitor’s battery failed. According to the Boston Globe, the monitor’s low-battery alarm had been going off for “about 75 minutes.”
◗ Another patient died after falling out of bed disconnected his ECG electrodes. The hospital staff didn’t respond to the resulting alarm, which they thought was due to artifact, until the housekeeping staff discovered the patient on the floor 30 minutes later.
◗  A 60-year-old Massachusetts man died in an ICU in 2010 after alarms indicating tachycardia and dyspnea went unanswered for almost an hour.
◗  A 17-year-old Pennsylvania girl died in 2012 of fentanyl-related respiratory depression after a routine tonsillectomy. The girl’s monitors had been muted and she suffered irreversible brain damage before nurses noticed something was wrong.


The terms “alarm” and “alert” are often used interchangeably, but they’re not the same thing. Alarms usually indicate a potentially life-threatening situation requiring an immediate response and are regulated by the FDA as part of the agency’s oversight of medical devices. By contrast, alerts are usually associated with non-medical devices and don’t indicate an immediate crisis. Some examples include nurse call systems and message notifications.

Alerts might be less critical than alarms, which is why they’re not regulated in the same way, but they both add to the general cacophony nurses face every day. Several studies have found that it’s difficult for most people to differentiate more than six different alarm sounds, but the American Association of Critical Care Nurses says the average ICU nurse must cope with more than three dozen sounds. It’s no wonder that alarm overload or alarm fatigue is becoming epidemic.


In the summer of 2013, The Joint Commission issued a new national patient safety goal (NPSG) regarding alarm safety. The NSPG is being implemented in two phases, which makes now a great time for you to get involved in addressing this serious problem.

In Phase I, which began January 1, 2014, The Joint Commission is calling on clinicians to help hospitals identify what types of alarms impact patient safety and which alarms just contribute to alarm fatigue. Doctors and nurses are also being asked to weigh in on questions like when it’s appropriate to disable an alarm or change the alarm parameters and who should make that call.

In Phase II, which starts Jan. 1, 2016, hospitals will use the data gathered in Phase I to establish and implement new policies and procedures for alarm management, which will include:

◗  Determining clinically appropriate settings for alarm signals
◗  When to disable or change alarm parameters and who has the authority to do so
◗  Appropriate routine monitoring and emergency response to alarms
◗  Maintenance of equipment for accurate settings, proper operation and detectability.

Those new procedures will undoubtedly have a big impact on how you provide care. Your input now will make a big difference in shaping those policies.

Alarm fatigue can be deadly, but nurses now have an opportunity to use their expertise to help improve alarm safety, enhance patient care and — hopefully — bring a little more sonic harmony to the unit.  


Sidebar: Alarm-Related Sentinel Events

According to The Joint Commission, alarm-related sentinel events (events that result in injury or death) typically have several contributing factors. The most common include:

◗   Alarm fatigue
◗   Improper alarm settings for a specific patient
◗   Inadequate staff training on medical equipment
◗   Insufficient staff to respond to alarms
◗   Alarms that aren’t integrated with other medical devices
◗   Equipment malfunctions and failures.


Sidebar: AACN Alarm Management Recommendations

The American Association of Critical Care Nurses has issued the following recommendations
for reducing false alarms:

◗   Prep the patient’s skin appropriately for ECG electrodes. That means soap and water served with a little roughage. Forget the alcohol wipe; it can dry out the skin and make it harder to affix the electrode.
◗   Change ECG electrodes daily — more often if needed.
◗   Customize the parameters of ECG and pulse oximetry monitors for each individual patient.
◗   Use adhesive pulse oximetry sensors. Forget the clip.
◗   Simplify monitoring by limiting it to patients who really need it.
◗   Educate the staff on the proper use of monitoring systems and how to respond to alarms.
◗   Collaborate with the entire healthcare team to identify and address alarm-related issues.


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