Alarm Fatigue: A Case Study

Patient safety is a universal topic shared among healthcare professionals. The Texas Board of Nursing (2007) mandates caregivers to “implement measures to promote safe environments for clients and others” and great efforts have been made to make observations, collect data and apply cutting edge technology to better serve patients. However, as new safety precautions have been executed to protect the patient, new hazards have emerged. One such hazard is the increased number of devices that have been fitted with alarms that beep, chime, and buzz, creating a noisy environment. This cacophony of competing sounds dilutes the value of each individual alarm, resulting in a phenomenom commonly referred to as “alarm fatigue”. Alarm fatigue can defeat
No standardized formula has been prescribed but rather The Joint Commission has given free agency to institutions that, “it is important for a health institution to assess its own situation and develop a systemic, harmonized approach to clinical alarm system management” (Elhabashy, 2015, 13). Executive decisions prioritizing and implementing an alarm management system should be developed by a multidisciplinary team made up of administration, physicians, nurses, nurse managers, patient safety management staff, IT staff, biomedical engineers, respiratory care practitioners, and monitor watchers/aides/techs on the unit (p. 16). According to Greg Spratt, director of Medtronic, three essential steps can greatly reduce alarm fatigue and improve patient safety. He begins with adjusting default alarms according to the area of care, suggesting, “lower acuity areas can be set “wider” while still providing adequate notification of significant changes in the patient’s condition” (Spratt, 2016, p. 14). Even more specific, customizing an alarm setting based on the patient’s individual needs, for example, “baseline etCO2 and SpO2 values for a patient with severe COPD would be significantly different than for a patient with healthy lungs” (p. 14). The second important step to reducing alarm fatigue is educating the patient and family, “experienced users report that by educating the patient and family prior to the procedure and reinforcing it during monitoring, patients are more likely to be compliant” (p. 15). The last influential step is educating staff members, as “a clear knowledge of the operation, alarm features, and limitations of monitors by the clinicians using the monitor is a key to assessing and understanding causes of alarms, and taking steps to reducing alarms” (p.