In January 2010, an elderly patient at Massachusetts General Hospital suffered a heart attack. Although the patient had been attached to a heart monitor, the monitor was turned off and nurses failed to respond to numerous lower-level alarms that warned of a lowered heart rate. In fact, 10 nurses on duty at the time could not later remember even hearing those beeps, or seeing the scrolling messages on the monitor. Unfortunately, the heart attack was fatal and the patient died. 

Alarm fatigue, which occurs when nurses and other health care workers hear so many alarms that they become desensitized to them, is a very real problem in the United States. While this problem is more common in hospitals, it all too often occurs in nursing homes too, especially when nursing home patients are hooked up to ventilators to monitor their breathing. A recent investigation by the Boston Globe showed that at least 216 deaths nationwide occured in hospitals and nursing homes because of alarm fatigue. However, experts believe that these incidents are severely under-reported and that there may be many more. 

In many cases, the nurses simply tune out the alarms. In others, staff have turned down or silenced alarms because with so many alarms going off they can’t work or concentrate. One study documented that a single, 15-bed unit at Johns Hopkins Hospital hears more than 900 alarms every day. Sometimes these noises condition staff to ignore low level alarms and pay attention only to the faster, higher-pitched alarms that signal a crisis – but when the lower pitched alarms are intended to let staff know that the batteries are failing or the device is not plugged in properly, ignoring them can lead to tragedy. 

Perhaps the biggest problem, however, is that there are so many false alarms. Most studies show that about 85% of all alarms are false. Some medical devices are so sensitive that they are set off when a patient rolls over in the bed, sits up or coughs. One study, published in the American Journal of Emergency Medicine, showed that 99.4% of alarms set off in one hospital’s emergency room were false. It’s hard to get nurses to feel a sense of urgency about alarms when so often they are wrong. Many experts feel that alarm manufacturers are unwilling to tone down the sensitivity of their alarms due to liability issues: if the alarm misses an event and doesn’t go off, the alarm manufacturer can be held liable for it. If, however, a nurse fails to respond to the monitor then she, not the manufacturer, is liable. 

The FDA is now poised to deal with the problem of alarm fatigue. The agency announced last week that they will be intensifying their pre-market review of medical devices that contribute to the alarm fatigue problem. FDA officials will require manufacturers to explain whether and how the alarms on their devices provide information of importance to patient care. In addition, the Joint Commission, a national organization that accredits hospitals, will undertake a survey of 4,500 hospitals and 1,000 nursing homes nationwide to come up with specific recommendations for reducing the number of alarms sounding. Some early suggestions include reducing the total number of alarms, monitoring how long it takes for nurses to respond to specific alarms and delivering alarms by beeper or cell phone. 

Some hospitals and nursing homes have already implemented aggressive steps to reduce alarm fatigue, including putting speakers in the hallways, hiring nurses and technicians whose sole job is to monitor alarms and changing batteries at a set time every day. 

More Information:
Patient Alarms Often Unheard, Unheeded
FDA working to trim hospital ‘alarm fatigue’
Family sues hospital, nurse after patient death linked to ‘alarm fatigue’