According to an investigation by the Boston Globe, between 2005 and 2010, more than 200 hospital-patient deaths were linked to problems with alarms on patient monitors.1 Don’t blame the devices, however. In many cases, these deaths occurred because medical personnel did not react fast enough or did not even notice the alarm—it’s called “alarm fatigue.”
“I think this is probably a much bigger problem than we realize,” says Paul Nuccio, MS, RRT, FAARC, director of pulmonary services at Brigham and Women’s Hospital in Boston (personal communication). “ICUs in particular are quite noisy with all the activity, equipment, and, of course, alarms. Many of the alarms sound similar. Some alarms can appear to be nuisance alarms, such as if the oximeter alarms whenever the probe falls off the patient’s finger. Nurses, therapists, physicians, etc, can become somewhat immune to these alarms, especially when some seem to be sounding the entire shift. Most alarms can also be silenced, just further adding to the problem.”
“The alarm hazards are a serious enough problem that they have ranked at or near the top of ECRI Institute’s Top Ten List of Health Technology Hazards for the last several years,” reports the institute.2
Most reports of alarm problems concern physiologic monitoring systems and ventilators, and typically involve alarm settings not being restored to their normal levels after being modified; alarms not being properly relayed to ancillary notification systems, such as paging systems and wireless phones—potentially leading to a failure to notify relevant staff; and staff becoming overwhelmed by the sheer number of alarms, which can result in staff improperly modifying alarm settings to reduce alarm overload, staff becoming desensitized to alarms, and/or staff so busy responding to alarms that they are unable to perform other critical duties.3
Some manufacturers are attempting to overcome alarm fatigue by developing “smart technology.” GE, for instance, is testing technology that uses information from a variety of physiological signals to evaluate patients.4 Philips, too, has a new product that promises to help address alarm fatigue or hospital staff dismissal of patient device alarms. The product gathers data from various patient monitoring devices, escalates the most critical and relevant patient information, and delivers that information to a provider’s handheld device.5 But, although manufacturers are trying to improve their machines, the devices must remain sensitive so no real crisis is missed.
What can health care facilities do to reduce the consequences of alarm fatigue? Among other suggestions, the ECRI recommends: establishing protocols that ensure that each alarm will be recognized, delivered to an appropriate responder, and promptly addressed; clearly assigning responsibilities, including the staff person responsible for recognizing the alarm; establishing backup coverage so someone is always available to respond; and establishing policies to control alarm silencing, modification, and disabling. To assist health care facilities in improving their alarm management, ECRI is hosting a webinar, “Don’t Kill the Alarm: The Time to Improve Alarm Management Is Now,” on May 18. You can check it out at www.ecri.org. Maybe your facility could benefit.
- Kowalczyk L. Patient alarms often unheard, unheeded. Boston Globe. February 13, 2011. Available at: www.boston.com/news/local/massachusetts/articles/2011/02/13/patient_alarms_often_unheard_unheeded. Accessed April 13, 2011.
- Don’t Kill the Alarm: The Time to Improve Alarm Management Is Now. Available at: www.ecri.org/Conferences/AudioConferences/Pages/Improve_Clinical_Alarm_Management.aspx. Accessed April 13, 2011.
- ECRI Institute’s 2011 Top 10 Health Technology Hazards. Available at: www.ecri.org/Forms/Pages/2011_Top_10_Technology_Hazards.aspx. Accessed April 13, 2011.
- Kowalczyk L. No easy solutions for alarm fatigue. Boston Globe. February 14, 2011. Available at: www.boston.com/lifestyle/health/articles/2011/02/14/no_easy_solutions_for_alarm_fatigue. Accessed April 13, 2011.
- Philips IntelliSpace Event Management solution offers enhanced platform for critical patient alerts (news release). Available at: www.newscenter.philips.com/main/healthcare/news/press/2011/20110412_intellispace.wpd. Accessed April 14, 2011.