Alarm Safety and Management

By: Jeremae Fajardo, Jose Murillo, Andrea Uranga

What is alarm fatigue?

Alarm Fatigue
Is when health care providers are
overwhelmed by multiple alarm signals
compromising patient safety.

Safety concern
19 out of 20 hospitals ranked alarm fatigue as the top
patient safety concern according to a national survey.
Hospital staff are exposed to an average of 350 alarms
per bed , per day based on a sample of an ICU unit at
the Johns Hopkins Hospital in Baltimore and 72-99% of
those alarms are false.
Thousands of alarms per unit and tens of thousands of
alarms per hospital each and every day.

Types of alarms
IV pumps

Blood warmer

Vital Signs machine

Cardiac monitor

Bathroom alarm

CPAP/BiPAP

Bed alarm

Care mobile

Wound Vac

Pulse Oximeter

Code Blue

Hugs (Code Pink)

Call Bell

I-STAT machine

Refrigerators

Negative Pressure
Room

Portable cardiac
monitor

A line monitor

Glucometers

SCD machine

Specialty beds

PCA pump

Ventilator

Emergency Exit
doors

The Joint Commission

Joint Commission named it a National Patient Safety
Goal.
TJC is now requiring accredited hospitals and critical
access hospitals to improve their systems.

2014 National Patient Safety Goal

NPSG.06.01.01 Improve the safety of clinical alarm systems.
Elements of Performance for NPSG.06.01.01
1. Leaders establish alarm system safety as a hospital priority.
2. Identify the most important alarm signals to manage based on
the following:
- Input from the medical staff and clinical departments
- Risk to patients if the alarm signal is not attended to or if it
malfunctions
- Whether specific alarm signals are needed or unnecessarily
contribute to alarm noise and alarm fatigue
- Potential for patient harm based on internal incident history
- Published best practices and guidelines

Cont.
3. As of January 1, 2016, establish policies and procedures for managing the
alarms identified in EP 2 above that, at a minimum, address the following:
- Clinically appropriate settings for alarm signals
- When alarm signals can be disabled
- When alarm parameters can be changed
- Who in the organization has the authority to set alarm parameters
- Who in the organization has the authority to change alarm parameters
- Who in the organization has the authority to set alarm parameters to off
- Monitoring and responding to alarm signals
- Checking individual alarm signals for accurate settings, proper operation,
and detectability
4. As of January 1, 2016, educate staff and licensed independent practitioners
about the purpose and proper operation of alarm systems for which they are
responsible.

Survey

Telemetry Survey Results

48 nurses in Telemetry unit were surveyed.
Agree
100
90
80
70
60
50
40
30
20
10
0

Disagree

88
58
42

56

44
12

Interventions to Reduce Alarm Fatigue

EKG Electrodes changed every day
Individualizing Alarm Parameters (example: pulse ox,
cardiac monitor, etc.)
Alarm management committee
Implement an alarm system configuration policy
Education training

Outcomes
Increased patient safety
Improve satisfaction scores
Compliance with TJC requirements

Policy

Training/Education

References

AAMI Foundation HTSI Clinical Alarms. Retrieved from

http://www.aami.org/htsi/alarms/

MacDonald, I. (2014). Hospital rank alarm fatigue as top patient

safety concern. FierceHealthcare, 2. http://www.fiercehealthcare.com

National Patient Safety Goals Effective January 1, 2014. Retrieved

from
http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.
pdf