Joint Commission Offers Recommendations on Medical Device Alarm Safety

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04/09/13
The Joint Commission offers guidance on how hospitals can best use alarm-equipped devices in a new Sentinel Alert (“Medical Device Alarm Safety in Hospitals”), which notes 98 reported alarm-related events over a 30-month period, including 80 that resulted in death of a patient.

In the Alert, the Joint Commission found instances of absent or inadequate alarm systems; improper alarm settings; alarm signals that were not audible in all of the necessary areas of the facility; and alarm settings that were inappropriately turned off. In addition to the 80 deaths, there were 13 incidents resulting in permanent loss of function and five requiring additional care out of the 98 alarm-related events reported between January 2009 and June 2012.

The Joint Commission says alarm-equipped devices are essential in providing safe care and aiding in making medical and treatment decisions in many settings, such as the emergency room, the intensive care unit (ICU), and the critical care unit (CCU). However, it can be problematic when one unit may produce more than 100 alarm signals daily, leading to desensitization and "alarm fatigue" among clinicians. In response to the frequent alarms, clinicians may turn them off, turn down the volume, or change the limits, which can have serious and often fatal results.

The Alert offers recommendations for hospitals to assess their use of alarm-equipped devices and develop a systematic approach to alarm safety. Among the recommendations:

  • Identify the default alarm setting and limits for each high-risk clinical area.
  • Establish guidelines for tailoring alarm settings and limits for individual patients.
  • Train clinical care team members on the process for safe alarm management and response in high-risk areas, the safe use of alarmed medical devices, and new alarmed medical devices.
  • Establish a cross-disciplinary team to address alarm safety and the potential impact of “alarm fatigue” in all patient care areas.
  • Establish a process for continual improvement and constant optimizing of alarm system policies and configurations.

The Joint Commission is an independent, not-for-profit organization that accredits and certifies more than 20,000 health care organizations and programs in the United States.

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