Alarm Fatigue, Patient Safety

90% of Patient Alarms Are “False”: Two recommendations for tackling alarm fatigue

The non-profit Connecticut Health Investigative Team [C-HIT] (www.c-hit.org) recently reported what Connecticut hospitals are doing to tackle a phenomenon known industry-wide as alarm fatigue.

As stated in their report “Hospitals Mobilize To Tackle Alarm Fatigue”:

Health care experts worry that medical devices with built-in alarms, such as heart monitors, infusion pumps and ventilators, designed to alert caregivers that patients are in danger could potentially put patients at risk because caregivers are desensitized by the sheer number of alerts and false alarms and fail to respond in a timely fashion. Research shows alarms in intensive care units are accurate less than 10 percent of the time, and 90 percent are false alarms.

The Joint Commission says that data from the U.S. Food and Drug Administration indicates that there were more than 560 deaths associated with monitoring alarms fin a recent four year period. A recent death of a 17-year old girl following a tonsillectomy from alarm fatigue underscores the need to address this critical safety issue.

“Alarm fatigue is a national problem. Excessive false alarms occur frequently and contribute to alarm desensitization, mistrust, and lack of caregiver response,” says Maria Cvach, MS, RN, CCRN (assistant director of nursing, clinical standards, The Johns Hopkins Hospital). “This may lead to staff disabling or ignoring alarm systems, which decreases patient safety.

From the C-HIT report, here are two recommendations to tackle alarm fatigue.

1. Use Smart Alarms.

Smart alarms that incorporate multiple vital signs or alert the caregivers by cellular phone or pager should be used by hospitals.

As James Keller (vice-president of health technology evaluation and safety, ECRI Institute) said, “Medical device manufacturers are developing smarter alarm systems that can indicate when a patient is trending in a certain direction.”

According to Ms. Cvach, an example of a smart alarm is one that analyzes “multiple parameters, like oxygenation and adequacy of ventilation, in a patient’s condition”.

In addition, according to C-HIT, some doctors at Bridgeport Hospital in Connecticut are using software that alerts their cellular phones and prioritizes patients based on their conditions.

2. Ensure patients know what their monitors and alarms are for.

Dr. Steven D. Hanks, executive vice-president and chief medical officer for the Hospital of Central Connecticut, says that hospitals should explain to patients and their families the role of alarms and what to do if they sound — “We need to do a better job of explaining how alarms work and what to expect if they go off”.

Above all, hospitals should remember the role and importance of monitors. Monitors provide “an electronic safety net” that supports periodic nurses’ checks. Says Michael Wong (executive director for the Physician-Patient Alliance for Health & Safety). “What are the odds of a nurse popping in at the very moment that a patient is experiencing difficulty? The odds are very poor. That’s why this technology is absolutely necessary.”

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