11 Recommendations to Reduce Alarm Fatigue-Related Errors

Establishing a process for safe alarm management and response is one way healthcare providers can mitigate alarm fatigue — the desensitization of healthcare workers and clinicians to medical device alarms — according to The Joint Commission.

The Joint Commission issued a Sentinel Event Alert for errors involving medical device alarm systems April 8. The Commission recommended 11 strategies to reduce patient harm related to alarm systems. The first five of these strategies are recommendations from the Association for the Advancement of Medical Instrumentation and ECRI Institute.


1. Leadership ensures there is a process for safe alarm management and response in high-risk areas (as identified by the organization).

2. Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions, and identify the default alarm settings and the limits appropriate for each care area.

3. Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions; include identification of situations when alarm signals are not clinically necessary.

4. Establish guidelines for tailoring alarm settings and limits for individual patients. The guidelines should address situations when limits can be modified to minimize alarm signals and the extent to which alarms can be modified to minimize alarm signals.

5. Inspect, check and maintain alarm-equipped devices to provide for accurate and appropriate alarm settings, proper operation and detectability. Base the frequency of these activities on criteria such as manufacturers' recommendations, risk levels and current experience.

6. Provide all members of the clinical care team with training on the organization's process for safe alarm management and response in high-risk areas and on the safe use of the alarmed medical devices on which they rely. Also provide ongoing training on new alarmed medical devices and updates to alarmed medical devices, and ensure new members of the clinical care team receive training on the alarmed medical devices.

7. To help reduce nuisance alarm signals, change single-use sensors, such as ECG leads, according to manufacturers' recommendations, unless contraindicated.

8. Assess whether the acoustics in patient care areas allow critical alarm signals to be audible.

9. Re-establish priorities for the adoption of alarm technology; the priority-setting process should drive technology adoption rather than allowing technology to drive the process.

10. Establish a cross-disciplinary team that includes representation from clinicians, clinical engineering, information technology and risk management to address alarm safety and the potential impact of alarm fatigue in all patient care areas.

11. Share information about alarm-related incidents, prevention strategies and lessons learned with appropriate organizations, such as AAMI, ECRI Institute, the FDA and The Joint Commission.

More Articles on Alarm Management:

Joint Commission Issues Alert on Medical Device Alarm Safety
AAMI Comments on Joint Commission's Proposed Alarm Management Patient Safety Goal

Joint Commission Proposes Alarm Management National Patient Safety Goal

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