title: Citing reports of alarm-related deaths, the Joint Commission issues a sentinel event alert for hospitals to improve medical device alarm safety.
abstract: As medical devices become more widely used in hospitals, there is evidence that providers are becoming overwhelmed by the alarms that emanate from these machines. Experts link the problem with 566 alarm-related deaths reported in an FDA database between January 2005 and June 2010, and 80 alarm-related deaths reported in The Joint Commission's (TJC) own sentinel event database between January 2009 and June 2012. The ED is among the hospital sites where the adverse events reported to TJC most often occurred. Providers in some hospital units have to deal with thousands of alarm signals every day, and an estimated 85% to 95% of these alerts don't require any intervention, according to TJC. Experts say with so much noise and so many false alarms, clinicians can become desensitized to the medical-device alarms. The types of alarms that administrators should be most concerned about in the ED are dysrhythmia alarms on heart monitors, oxygen saturation alarms, and signals that a patient has a low respiratory rate. Experts urge hospitals to develop cross-disciplinary teams to address alarm safety on an ongoing basis, and to assemble action plans for improvement that contain baseline metrics that can be used to chart progress.
mesh_terms: D001305:Auditory Fatigue; D056902:Clinical Alarms / Q000009:adverse effects* / Q000592:standards; D004636:Emergency Service, Hospital / Q000592:standards; D017052:Hospital Mortality; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D058996:Quality Improvement; D017751:Safety Management / Q000592:standards*; D014481:United States