Tackling Alarm Fatigue: An opportunity to save lives

A delay in responding to a clinical alarm can be deadly

While assessing clinical practices and operations at a different hospital almost every week, I am often amazed at the ability of members of the care team to manage their duties and responsibilities in such a professional manner, despite the onslaught of so many competing priorities – give meds on time, document everything, attend care team conferences, and so on.  Of course, many nurses resort to taking short cuts and make decisions to prioritize various tasks over others in order to focus on what is important at that moment.  A casualty of this constant clamor to complete tasks, re-prioritize others and respond to  emergent issues is that alarms emanating from patient monitoring devices are often ignored.

Over the years, hospitals, the Joint Commission and the media have occasionally scrutinized the problem of alarm fatigue but the lack of constant diligence and focus has helped to make this an issue that remains a lower priority than it should be.  Any health professional that does not give due respect to this issue would do well to read the following blog post on the Findlaw.com legal information website making it clear that the medical malpractice community is fully aware of the impact of alarm fatigue.

 

The Boston Globe, the only media outlet that has been following the issue, reported in a two part series earlier this year that some 200 patients died in hospitals between 2005 and 2010 where death was linked to the failure of health care professionals to respond to alarms.  The article cites a study carried out on a 15 bed unit at Johns Hopkins Hospital in Baltimore where an average of 942 alarms per day were recorded, one of which was deemed critical every ninety seconds.  As someone who spends a considerable amount of time observing nursing practices in-situ every week, this figure seems to be well aligned with reality.

A couple of specific cases cited by the Boston Globe which ended in tragedy include a case at UMass Memorial Medical Center in Worcester, where an alarm designed to alert nurses to replace an exhausted heart monitor battery went unanswered for seventy five minutes.  The patient’s hear subsequently failed and the monitor could not signal an alert that could have saved the patients life.  In a second case at Massachusetts General Hospital, a crisis alarm on a patients cardiac monitor was turned off and nurses did not respond to “lower level” alarms warning of a low heart rate.  State investigators in this case found that nurse had become desensitized to the alarms, something that most health care professionals in an acute care setting can relate to.

So what is to be done?  At this point it appears that the FDA, Joint Commission and other unnamed industry groups may be formulating standards and best practices around responding to clinical alarms, per this recent Boston Globe Story.  Regardless of what standards and expectations are developed, hospital and clinical leadership needs to take ownership of this issue in collaboration with nurses, phsicians and other members of the care team such as respiratory therapists, pharmacists, physical therapists, unit secretaries and monitor techs.  Policies should be developed that define alarm levels, expected response to these levels and next steps to be taken by staff in the event that a responsible individual is engaged in an emergent situation, off the unit or otherwise unable to respond.  Expectations and accountability need to be aligned carefully with the principles of a blameless culture where reporting of issues is encouraged.  Finally, the organization should develop reports that provide benchmark and ongoing data on predefined quality parameters in order to determine progress and areas for managers to focus on in order to attain the highest level of compliance.

Patients and their visitors also have a role to play in ensuring alarms are responded to in a timely manner.  Not being afraid to remind a nurse about an alarm that has gone unheeded for some time, reporting any changes in the patients visible condition and being a constructively squeeky wheel are all appropriate behaviors.  Healthcare organizations could even ensure that patients and their visitors know that responding to certain alarms immediately is a high priority and that their help in this regard is appreciated.

An organizational focus on responding to alarms in a timely and appropriate manner is highly likely to yield positive improvements in patient satisfaction, clinical outcomes, relevancy of clinical documentation and staff morale/effectiveness of the care team.

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3 Responses to Tackling Alarm Fatigue: An opportunity to save lives

  1. HC2011 says:

    Totally agree with your comment about patients and visitors playing a part in alarm response. If you are visiting a family member in the hospital and a pump starts beeping you should inform the unit secretary or nurse immediately.

  2. Thanks for your comment HC2011.

  3. vora_P says:

    All staff need to take ownership of this one. If you hear an alarm beeping and believe it has not been checked, say something, whether you are a tech or physician or surgeon

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