Ignoring Hospital Alarms, Warnings Linked to Patient Deaths: Report

Medical device alarms play a larger role in hospital injuries and fatalities than previously thought, according to an alert issued by an independent, non-profit healthcare group.

According to a statement released by the Joint Commission, which accredits and certifies more than 20,000 health care organizations and programs in the U.S., confusion caused by similar sounding alarms or warnings provided by devices used during hospital treatment may be contributing to patient injuries and deaths.

Medical device alarms are used in many clinical settings, such as monitoring pulse, blood pressure, telemetry and are also used in electrocardiogram (ECG) machines, central station monitors, infusion pumps and ventilators.

Multiple types of machines are necessary for care in a hospital, with many of them having similar sounds or sounding at the same time. These situations cause confusion or, worse, desensitize the healthcare staff to the point that they ignore the alarms, according to the Joint Commission report.

In a Sentinel Event Alert issued April 8, the Joint Commission indicates that medical device alarms, which are necessary to provide safe and vigilant care to patients in a clinical setting, may also be the very cause of many injuries and deaths. One patient can experience several hundred alarm signals in one day. When that is translated to multiple patients in a hospital setting, it can result in thousands of medical device alarms sounding each day.

About 85% to 99% of those alarms do not require clinical intervention. This results in many healthcare professionals experiencing what they call “alarm fatigue.” This can lead to them becoming desensitized to the noise and sometimes becoming overwhelmed by the alarms themselves.

Many medical device alarms create similar sounds when set to default specifications. As such, many healthcare providers will turn down the volume of the alarms, turn off the alarms or misadjust the settings of the alarms, potentially resulting in serious consequences.

These simple oversights translate into more than two dozen deaths each year, according to the group. The commission’s voluntary event database reported 98 alarm-related events from January 2009 through June 2012. According to the report, 80 of them resulted in death and 13 patients experienced a permanent loss of function. Of the events, 94 occurred in a hospital in emergency, intensive care or general medicine departments.

The FDA’s adverse event reporting database indicates that there may have been 566 alarm-related patient deaths from January 2005 to June 2010, according to the group. In spite of the large numbers of fatalities and complications related to medical device alarms, officials from the commission believe deaths and injuries related to medical device alarms are still severely underreported.

Many of the medical device alarm events were related to patient fall accidents, delays in treatment and medication errors. Factors which contributed to the injuries or death include, inadequate or missing alarm systems, incorrect settings, inaudible alarms, equipment malfunctions and the most common contributing factor, “alarm fatigue” by healthcare professionals.

Adequately functioning alarms aid in the appropriate care and treatment of patients. The underreporting of alarm-related deaths is attributed to alarm complications. Misused or malfunctioning alarms can result in a chain of events which cause further complications for patients and may eventually lead to injury or death, making it difficult for administrators to determine the initial cause of the problem and trace it back to the device alarm.

Officials recommend preparing an inventory of alarm equipped medical devices which can be used in high risk areas such as the emergency room or intensive care unit to help prevent high injuries or fatalities caused by medical device alarm complications. Other options include establishing guidelines for alarm settings for the individual or a population of patients, inspecting devices and offering more training and education to the clinical care team to help prevent serious or fatal consequences.