Healthcare News & Insights

Are your physicians immune to the sound of medical device alarms?

Electrocardiogram (ECG) machines, pulse oximetry devices, blood pressure monitors, infusion pumps, ventilators — and the list goes on — all have alarms in them to warn healthcare professionals when something isn’t right. But are your nurses and doctors hearing them?

monitorAccording to a Sentinel Event Alert issued by The Joint Commission, they might not be.

Reason: Nurses, doctors and other healthcare providers become desensitized to the alarms. The report refers to the phenomenon as “alarm fatigue.”

And, unfortunately, it happens often enough that ECRI Institute has listed it as the first or second most critical hazard in its annual Top 10 Health Technology Hazards report since 2007.

In fact, the U.S. Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database sited 566 alarm-related patient deaths between January 2005 and June 2010.

Under-reported event

If you’re thinking that doesn’t seem like a lot considering it’s over a five-year time span, you should know that 566 represent the number of reported alarm-related patient deaths. Industry experts recognize the fact these events are under-reported. And considering they happen in all healthcare settings, that’s scary.

It obviously happens a lot, since a Sentinel Event Alert was published on it.

A sentinel event, according to The Joint Commission, “is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, or the risk thereof, includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  Such events are called sentinel because they signal the need for immediate investigation and response.”

Cause of alarm fatigue

The problem is, it’s estimated that between 85% and 99% of all alarm signals don’t require clinical intervention.

When you consider the fact that one patient can trigger several hundred alarm signals in one day, and multiply that by all the patients in a hospital, the numbers add up to tens of thousands of patient alarms going off every day.

With all that noise, it’s no wonder that some clinicians adjust the alarm settings, turn down the volume of the alarm settings or even turn them off. However, all of these actions can have serious and even fatal consequences. Practitioners may miss a vital warning that a patient is in trouble and needs immediate attention.

The Sentinel Event database found that of the 98 alarm-related events that occurred between January 2009 and June 2012, 80 resulted in a patient’s death, 13 in permanent loss of function and five in unexpected additional care or extended stays. And 94 of the 98 events took place in a hospital, with the majority occurring in telemetry, intensive care, general medicine and emergency department areas.

The most prevalent factors that contributed to the reported events were:

  • absent or inadequate alarm systems
  • improper alarm settings
  • alarms not being audible in all areas, and
  • alarms being turned off.

But they aren’t the only things that lead to the events — just the major one. Each sentinel event can have a number of contributing factors, such as:

  • alarm fatigue — the most common
  • settings not customized to individual patients
  • inadequate staff training on use of equipment
  • inadequate staffing to respond to alarms
  • alarms not being integrated with other medical equipment, and
  • equipment malfunctions.

Improvement strategies

At present, the Joint Commission is looking at creating a National Patient Safety Goal which would address this major patient safety issues.

But the Commission also knew something had to be done immediately to reduce patient harm related to medical device alarm systems. That’s why it’s been working with the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute to develop recommendations that’ll help reduce these events.

Some of the recommendations they’ve come up with include:

  • create processes for safe alarm management and response in high-risk areas
  • set limits for default alarm settings in each high-risk area and for high-risk clinical conditions
  • develop guidelines for alarm settings in high-risk areas and clinical conditions, and when alarms aren’t clinically necessary
  • tailor alarm setting and limits for individual patients, including when they can be modified, and
  • inspect, check and maintain alarm-equipped devices on a regular basis for accurate and appropriate alarm settings.

The Joint Commission goes even further with its recommendations, suggesting that hospitals need to concentrate on providing more in-depth training to the entire clinical care team on the facility’s processes for safe alarm management and response in high-risk areas.

One final piece of advice from the commission: Hospitals should start testing the acoustics in their patient care areas to see if providers actually can hear critical alarms when they go off.

To read the full Sentinel Event Alert: Medical Device Alarm Safety in Hospitals, which also provides relevant standards, click here.

 

 

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