Joint Commission issues alert for medical device alarms

Calling alarm events a “frequent and persistent problem,” the Joint Commission issued a Sentinel Event Alert to hospitals, imploring leaders to examine the serious risk caused by alarm fatigue from medical devices.

“These alarm-equipped devices are essential to providing safe care to patients in many healthcare settings; clinicians depend on these devices for information they need to deliver appropriate care and to guide treatment decisions,” according to the alert. “However, these devices present a multitude of challenges and opportunities for healthcare 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.”

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, according to the organization. Alarm conditions may be set too tight, default settings are not adjusted for the patient or patient population, ECG electrodes may dry out or sensors may be mispositioned, among other reasons for these alarms. Consequently, clinicians may become immune to the sounds, turn down the volume, adjust settings outside safe limits or turn the alarm off.

The Sentinel Event Alert includes 11 recommendations of strategies for improving safety related to medical device alarms, including several under the categories of training and education, equipment and physical environment and leadership and organizational planning. The alert also says that the Joint Commission may develop a related National Patient Safety Goal.

Text of the alert is available here.