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year period ending last year it had received
98 reports of alarm-related incidents, includ-
ing 80 deaths. In a majority of these cases
functional alarms were disabled or were
inaudible, thereby failing to alert staff of a
problem with the patient. Hospitals are not
currently required to report alarm-related
incidents, so experts speculate the prob-
lem is, in reality, significantly greater. That
prompted a Joint Commission Sentinel Event
Alert on Alarm Safety this April, which was
quickly followed by a new National Patient
Safety Goal (NPSG.06.01.01) that will go into
effect in July, 2014.
It’s not the first time Joint Commission
has expressed concern about alarm fatigue.
The ECRI Institute, too, has listed alarmhaz-
ards as the number one health technology
danger in its annual top ten listing for the
last two years.
While most hospitals are aware of the
challenges around alarm management and
the danger of alarm fatigue, there is nothing
quite like a Joint Commission nudge to get
them to take a closer look and ensure they
are ready for the newPatient Safety Goal.The
Joint Commission itself admits “universal
solutions have yet to be identified,” but is
compelling hospitals to “develop a system-
atic, coordinated approach to clinical alarm
systemmanagement.”
Although St. Tammany Parish Hospital’s
Safety Council had already started address-
ing the alarm issue in January when it started
appearing in the literature, Chief Operating
Officer Sharon Toups said the Sentinel Event
Alert reinforced that focus. “When we get a
Sentinel Alert like the one Joint Commis-
sion put out, we normally take a proactive
approach of reviewing our policies and
procedures and look for opportunities
where we might be able to improve a
situation, and that’s prettymuch what
we’ve done with alarms.”
Slidell Memorial Hospital Risk
Manager Diane Surla agreed. “It’s
something we look at on a regular
basis just froman environment of care
perspective. Tomake sure we’ve evalu-
ated any safety processes and evaluated
any nursing processes, or even from a bio-
medical engineering standpoint, evaluated
their preventive maintenance of the alarms
to be sure that they are set appropriately to
focus on patient safety. With the Sentinel
Event Alert it brings even more focus to us
to evaluate our processes and establish the
guidelines and the standardization that we
may need to implement or just to review our
current processes.”
“Any time we get a Sentinel Event Alert
we form a team to start looking at how that
alert impacts our facility, said Sherry Col-
lura, Patient Safety Director at North Oaks
Medical Center. “So when that came out we
formed our teamand started inputting some
things into our processes related to clinical
alarms. We actually toured the units, listened
to the alarms, talked to the staff, talked to the
physicians, listened to some webinars, and
got some sample information from ECRI,
which has put out several webinars about
alarm fatigue. We’re addressing each one
It can be a
difficult lesson
for clinicians:
just because we
can monitor
something, doesn’t
always mean we
should.
alarm/monitor photos courtesy Woman’s Hospital