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Too Many People Are Dying From "Alarm Fatigue," Reports Joint Commission

Apr 08, 2013 04:31 PM EDT
Patient With Doctor
The Joint Commission released an alert on Monday calling attention to a phenomenon its calling "alarm fatigue."
(Photo : Reuters)

The Joint Commission issued an alert to medical workers on Monday regarding the tendency of some to block out beeps from the machines they work with - a state the group is calling "alarm fatigue."

"These alarm-equipped devices are essential to providing safe care to patients in many health care settings," stated the report. Despite this crucial role, however, the report warns that they can become a detriment when they "create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals."

In fact, the alert reported that the number of alarm signals per patient per day can reach several hundred, 85 to 99 percent of which do not require clinical intervention. 

"As a result, clinicians become desensitized or immune to the sounds, and are overwhelmed by the information - in short, they suffer from 'alarm fatigue,'" it reads.

In response, the alert explains, some medical workers turn the alarm settings outside of what is actually appropropriate for the patient, or off altogether. 

This was the case in the 2010 case of a 60-year-old man who died in the intensive care unit "not from the injury he suffered to his head from a fallen tree branch - but from a system failure that resulted in delayed response to an alarm signal that indicated significant changes in his condition," including a rising heart rate and falling oxygen levels.

"Staff resopnded only after one hour, when a critical alarm condition signaled that the patient had stopped breathing - but the damage had been done," the alert states.

The man suffered significant brain damage and was removed from life support just several days later.

In all, the Joint Commission's Sentinel Event database includes reports of 98 alarm-related events between January 2009 and Jun 2012, 80 of which resulted in death, 13 in permanent loss of function and five in additional care or extended stay.

For this reason, the organization issued several strategies to address the problem. These included extra training on alarm management as well as new medical devices and always checking to make sure a person's critical alarm signals are audible. The group further called for the establishment of a cross-disciplinary task force comprised of clinicians, clinical engineers and representatives from both IT and risk management to review trends and devise solutions to the problem.

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