Alarm Fatigue: Patient Safety in Today's Healthcare Marketplace - A Four Part Series
One of the greatest challenges in today’s rapidly changing healthcare system is maintaining the highest standards for patient safety. In part two of this four part safety series, we talked about the issue inadequate skill mix on nursing units. This week, we’ll focus on the major safety issue of alarm fatigue.
As nurses, we are bound by our oath to give quality care to every single one of our patients. As we enhance the delivery of our healthcare practices with high tech, state of the art electronics and devices, alarms have been created to alert nurses of changes in the status of our patients. Although these alarms are quite loud and would normally elicit a concerned response, in an already overwhelming and chaotic work environment, those extra noises may have a less than desirable effect when it comes to patient safety.
What is the Issue?
RING! BEEP! DING! BING! These are the sounds of a typical busy nursing unit. Though alarming (no pun intended) to someone less familiar with this environment, it becomes background noise to experienced nursing staff.
Since it's easy for nursing staff to be overwhelmed, distracted, and even desensitized to the alarms around them, they begin to experience what is called "alarm fatigue". They respond by ignoring the alarm, turning down the volume of the alarm, turning off the alarm completely, or adjusting the alarm settings outside the limits that are considered to be safe and appropriate for the patient. All these can have serious, and sometimes fatal consequences. The US Food and Drug Administration has reported over 500 alarm-related patient deaths in the last five years. According to The Joint Commission, "In 2013, a 60-year-old man died in an intensive care unit of a hospital-not from the injury he suffered to his head from a fallen tree branch-but from a delayed response to an alarm signal that indicated significant changes in his condition."
Also, from my own personal experience, I'm often surprised when I work at the bedside how few nursing staff react to the sound of a bed alarm or telemetry monitor alarm. Perhaps I react more assertively to the bells and whistles because I only work at the bedside part-time, but regardless of that fact, I still find myself taken back by the observed lack of urgency from the staff around me when patient care alarms are ringing.
Why causes alarm fatigue?
First, let's point out the fact that it is quite difficult to differentiate between all the sounds going on in a nursing unit. Many medical devices in healthcare centers have alarms that sound similar. Bedside monitors (including electrocardiogram or ECG machines), pulse oximetry devices, blood pressure machines, telemetry monitors, central station monitors, infusion pumps, hospital beds and ventilators all have similar "beeping" sounds that may alarm continuously regardless of a change in a patient's status.
Also, it is nearly impossible for nurses to attend to every alarm sounded. Research shows that the number of alarm sounds per shift can reach up to 1,000 depending on the type of unit. Of those alarm sounds, the majority of them are shown to be non-emergent, usually relating to electrode misplacement, or settings being too tight for the patient's status.
What can be done?
The Joint Commission has required that all healthcare facilities implement comprehensive policy reform regarding alarm fatigue and that they set strict guidelines for appropriate clinician responsiveness to alarms. Here are some of the plans already in progress:
Improved clinician education - The American Association of Critical Care Nurses mandates initial and ongoing education related to patient care equipment and alarm response. This education includes proper technique for application of devices, alarm settings, and policies regarding appropriate response times and required documentation.
Prevention of over-prescribing alarm producing monitoring equipment - The National Association of Clinical Nurse Specialists recommends that nursing take a collaborative approach at assessing the clinical indications for patient monitoring equipment, such as telemetry or continuous pulse oximetry when it is ordered by a care provider. In some instances, a patient with nausea and vomiting will be ordered for telemetry, although they do not meet criteria for a heart monitor during their inpatient stay. This should be discussed with the covering physician to determine need, thus possibly reducing the incidence of alarm fatigue.
Advocate for Peer Accountability - It is recommended that we speak with our colleagues at regular intervals regarding observed evidence of alarm fatigue. If you see other nursing staff sitting near a monitor that is alarming, remind them that it is our responsibility to continuously monitor the patients, and that includes responding to all the bells and whistles. You'd be surprised on how many nurses claim that they didn't even hear the alarm going off, and by redirecting their attention to the severity of not hearing them, they become more vigilant in listening for and responding to the alarms.
As we push forward in working hard to correct the alarm fatigue within our healthcare facilities, I am confident that our devotion to upholding the highest standards for patient safety will lend itself to creating positive change for all.
Last edit by Joe V on Jun 18
About Damion Jenkins, ADN, MSN
Hi! I am Damion - a Registered Nurse, Educator, Tutor and Writer! I am the owner and operator of TheNurseSpeak.com - a nursing education and consulting company & blog. I love to help nursing students, new graduates and nursing professionals alike to develop strategies for success!
Joined: Nov '17; Posts: 47; Likes: 97
Nurse Education Consultant, Tutor and Writer; from MD , US
Specialty: 7 year(s) of experience in Individualized TutoringJun 19Joined: Jul '16; Posts: 680; Likes: 1,561Agree that all the alarms are a huge problem, not to mention carrying around the work phone for every yahoo to call you all day. Not sure I agree that Joint Commission is the answer to the problem. More education is not needed, and definitely not more regulation regarding "appropriate responsiveness and required documentation"; also do not agree that nurses need to be reminding each other of their responsibilities all day. Nurses know what needs to be done, and as usual, Joint Commission regulations will cause more harm than good. I think that decreasing alarms (and phone calls) to a bare minimum, along with giving nurses time to do what they already know needs to be done would solve the problem.Jun 20Occupation: ER RN Specialty: 24 year(s) of experience in ER ; From: FL, US ; Joined: Dec '16; Posts: 149; Likes: 780I like the article. Our work environment is cluttered with noise. But, just because no obvious action is taken every time an alarm sounds does not mean the alarm was not evaluated. Often a quick glance at the screen, especially when I'm with the patient, shows that artificial intelligence has outdone itself once again.Jun 20Joined: Oct '08; Posts: 2,068; Likes: 10,015- One cannot discuss alarm fatigue without discussing staffing. This is at least two-fold: 1) There has to be adequate availability of staff to physically respond to alarms (check the patient), and 2) By basic definition, the availability of alarms is a benefit that does, or is used to mitigate staffing needs. Think about it. If there were no alarms on monitors then the only way to benefit from monitors would be to have a staff member constantly looking at them. That is not necessary because staff can leave the patient's immediate area and be summoned back by an alarm. So whether it is acknowledged or not, the availability of alarms permits staffing arrangements that allow for less-frequent eyes-on monitoring of patients (known as surveillance).
- One cannot discuss alarm fatigue without a discussion of the rapidly mounting documentation requirements and other distractions that serve the business but not the patient.
- One cannot discuss alarm fatigue without acknowledging wrong responses to the problem. Specifically, sending alarm notifications to phones **doubles** the "inappropriate alarm noises" problem instantly - by definition. Requiring documentation of response to each alarm while at the same time acknowledging the number of them that are false or inappropriate is utterly nonsensical and will increase the problem.
- One cannot discuss alarm fatigue without discussing the inappropriate attempts to elevate everything to the level of emergency. Such as an intervention to send all "bathroom" and "pain" call lights to *every staff's phone on the unit*
- Glad to know TJC looks to and quotes the Boston Globe in its Sentinel Event reports.
Here is the/an article discussing this, and here is one selected quote of interest (emphasis added):
A study at Hopkins, led by Cvach in 2007, documented an average of 942 serious alarms per day - about one critical alarm every 90 seconds - on one 15-bed unit. Other studies have found that more than 85 percent of alarms are false, meaning the patient is not in any danger.
Hopkins has been trying to eliminate false alarms caused by patient movement and by slight changes in a patient's condition that don't require additional care.
It reduced alarms on one unit from 300 per patient per day to 100 per patient per day, Cvach said. But "even if there are 100 alarms per patient per day and a nurse has three patients, that's still a lot of alarms a nurse has to deal with,'' she said. "We still haven't conquered the problem.''
Even in trying to be conciliatory they have failed to grasp the problem.Last edit by JKL33 on Jun 20Jun 20Joined: Jun '02; Posts: 2,234; Likes: 5,095We used to have a tele tech and it was wonderful, someone who could devote themselves to the monitors so the nurses could focus on the patients. Then to save a buck and get more CNA's the tech position was eliminated and lots of tele banks with loud alarms were installed at the nurses station and throughout the halls. That just added to the stress level and it is simply impossible to watch the alarms while you are in patients rooms, for instance. So now we have phone alarms and we are constantly subjected to buzzing and blaring non-stop duplicate alarms and the worst part is most of them probably 90% are false alarms! Try talking to a Dr on the phone while the alarms keep blaring in. Ridiculous! The alarms are one of the main reasons I refuse to work extra!
When I worked on a vent unit the vent alarms were actually legitimate and warned of problems not false as the tele alarms. But most of the tele alarms are just useless noise distracting and frustrating. If hospitals really cared about safety they would bring back the tele techs!Jul 3Occupation: Nurse Education Consultant, Tutor and Writer Specialty: 7 year(s) of experience in Individualized Tutoring ; From: MD, US ; Joined: Nov '17; Posts: 47; Likes: 97I want to thank everyone for contributing to this very important discussion! Your feedback and insight is greatly appreciated as we all have varying perspectives which are all valuable for improving upon the practice of nursing excellence!
Keep up the great work!
DamionJul 4Occupation: travel nurse Specialty: 17 year(s) of experience ; From: IL, US ; Joined: Jul '08; Posts: 27; Likes: 24I just responded to a poster that submitted "how I stopped worrying and learned to love the monitor". It somewhat references alarm fatigue and I posted the words below. While I personally dislike joint commission on this one they did hit the mark but without any real message on how to.
One pt stands out in memory. In for persistent V tach, she was going to see an electrophysiologist. Therefore she rang a critical value alarm continuously. But this pt had a pulse throughout her entire stay. As we were in a cardiovascular ICU with post op CABGs, post cath pts and generally sick pts, how do you safely monitor everyone else. Fortunately she had an arterial line and we were only going to treat her if she changed to pulseless vtach. So, I changed her alarm to aline to the critical value, greatly narrowed the parameters, and put vtach on message. Finally, quiet came over the unit. Everyone was told about the changes and I felt the pt was more accurately monitored for what we were going to and need to respond to.
Imagine my disappointment when the next day I was called into managers office and told that this was inappropriate. Like we needed the constant reminder th pt had vtach with a pulse.
Anyway my response to the other article is below. I find that a lot of people blame the monitors when they are only telling us what we asked them to.
"I like the topic. I try to get my coworkers to love the monitor as much as I do. Alarm fatigue is a huge issue. So make the monitor work for you. Adjust alarms so they are appropriate. This might include limits or the alarm value. For example narrowing rate alarms,ie if I have a pt on cardiazem or amiodarone, raise the lower to 60 or 70 as the med might be *too effective * and lower upper to 110-120 after gaining some control so you know if med is ineffective.*
Also know lead placement. Frequently I receive a pt who rings for asystole all day due to one lead reading that has such a low amplitude that it does look like that. Placement may have to go way off standard to get all leads to read. Remember the monitor reads all, not just the display lead. Also, pacemakers are sometimes challenging as leads may have to be moved to accommodate. You can go to your manual for the monitor to see the changes needed.*
Review the limits, know the reasons for false alarms and how to fix them . Even frequent artifact can be and needs to be corrected. The wires themselves may be microfractured and need to be replaced.
Sounds like you learned to always check the pt first in the case of alarm. I just want to say help the monitor work for you."
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