TJCWhile hospitals depend on an array of alarm-equipped devices to collect information necessary to providing appropriate care to patients, these devices present a host of challenges for clinicians. According to The Joint Commission, nearly 100 adverse events involving alarmed medical devices occurred between January 2009 and June 2012.  Eighty of these events resulted in a patient death, and in 13 of the cases, patients experienced permanent loss of function.

TJC has issued a Sentinel Event Alert  aimed at warning hospitals of the many dangers presented by medical device alarm systems and identifying opportunities to improve alarm safety.

Out of the tens of thousands of alarms that echo through hospitals every day, between 85 and 99 percent of the signals do not require any sort of staff intervention.  For this reason, clinicians often turn the volume down on the alarms or eventually develop “alarm fatigue” and become desensitized them.  Ignoring these alerts or assuming them to be false or nonemergency alarms, however, means that clinicians are not receiving vital warnings of impending trouble with patients who may need immediate attention.

TJC is also considering establishing a National Patient Safety Goal aimed addressing this serious patient safety issue.  In the meantime, the agency has worked with organizations including the Association for the Advancement of Medical Instrumentation (AAMI) and  ECRI Institute to develop recommendations that could help reduce patient harm in the short term. These recommendations include:

  • Establish processes for safe alarm management and response in high-risk areas
  • Identify and set appropriate limits for default alarm settings for equipment used in high-risk settings
  • Establish guidelines for identifying situations when alarm signals are not clinically necessary
  • Establish guidelines for tailoring alarm settings and limits for individual patients
  • Regularly inspect, check and maintain alarm-equipped devices depending on provisions of manufacturers, risk levels and experience

Additional strategies being suggested by TJC include providing more thorough and consistent training regarding the use of alarmed devices for entire clinical care teams as well as assessing the acoustics in patient settings to determine how audible a sounding alarm would be for clinicians.

To learn more about TJC’s recommendations for addressing medical device alarm safety, click here.