Wednesday, September 15, 2010

Alarm Fatigue

I was cooking a BIG meal – one with several burners going, the oven on, and even the microwave.  It was one of those “Martha Stewart has nothing on me moments.” (Ok, I was really more like a I'm a tall version of Rachel Ray) There were 4 boys running in and out asking questions and trying to “help” - other kitchen noises like the garbage disposal, can opener, food processor plus of course the TV was on in the other room. It was loud - like the Chiefs Stadium when we beat the Chargers on Monday night – LOUD! The point is I had a lot going on and neglected to set the egg timer for one of my pans and ignored the beeping on the oven……all of this to say we ended up eating at Culvers that night.

My kitchen scenario is much LESS intense than a nursing floor. No one was critically ill, there were no emotionally distraught family members, there was no Code Blue – it was a kitchen. (Well, the food was critically ill by the end of it – I digress) The point is think about your most intense - loud - busy moments and then think of how much more intense - loud - and busy the nurse is and you will begin to understand  “Alarm Fatigue”.

On a floor with 30 patients with IV pumps, nurse call, telemetry, other physiological alarms, etc there is bound to be some noise. The current methodology of listening for an alarm can really hinder productivity – but leave productivity out of it – it is a major safety concern.

Let’s take an easy one - Do you know the most common way we document a response to an IV pump alarm? The patient has pressed their call button and the nurse is notified that the IV Pump was dinging in their room. Think about how scary that is for a patient and their family – who has no idea what the dining means. Do you know the most inexpensive way to fix that problem? Automate an IV pump alarm to the caregivers wireless and explain to the patient and their family what will happen if the alarm goes off. (BTW – repeat that information every time you enter the room for rounding.)

Here’s a freebie - Depending on your nurse call system there is generally a quarter inch jack that can take a contact closure alarm – old school – this is the way my Dad did it when he sold nurse call in the early 1980’s. Order the cord you can use it tomorrow in your hospital. IF you have a question (hospital) – call or email me I will walk you through it. There are much more expensive ways to automate these as well.

The challenge is at some point in alarm automation and “management” you simply begin to displace the problem. If a clinical alarm device is trigger happy then your wireless device will be as well. Too many alarms is still TOO MANY ALARMS – just because it’s quieter on the unit does not mean its better. At some point it’s time to really review the technology that is making the alarm happen, AND review the process of who is getting what alarm when and why. The event in Boston was not due to the alarm noise, really it wasn’t even due to accountability because no one “heard” the alarm. The Critical alarm was turned off and the Warning alarms were ignored. Some automation would’ve helped the issue but it may not have solved.

Patient safety officials across the country have said the heart patient’s death at Mass. General shines a spotlight on a national problem with heart sensors and other ubiquitous patient monitoring devices. Numerous deaths have been reported because of alarm fatigue, as beeps are ignored or go unheard, or because monitors are accidentally turned off or purposely disabled by staff who find the noise aggravating.  ()

It’s tragic that a death occurred due to an alarm issue, and no family should have to go through that.  That death should be a rally point for all of us in the device industry.  


  1. "If a clinical alarm device is trigger happy then your wireless device will be as well."

    Love this point. Alarm fatigue can come from many sources, including a wireless phone. Tuning the sources of alarms is key. Making sure that there is increased visibility to that which really matters, rather than that which is already being ignored.

  2. As a nurse, your phrase "AND review the process of who is getting what alarm when and why." really hit home. Alarms are set for a reason...they need to be sensitive for changes in a patient's condition and they need to alert those caring for the patient. In July, AJN published a news item about this incident (here's the link: and stressed the fact that while we can't eliminate alarms, in an ideal world, false or "nuisance" alarms are minimized and different pieces of technology would have unique sounds.

    When I worked in ICU, alarms rang all the time, and we all got up and ran when we heard a "three-star alarm" which meant a life-threatening arrhythmia. We knew the sound if someone was off the monitor, the beep of an occluded I.V. line, or if a patient needed to be suctioned and the high pressure alarm was sounding. It doesn't take long to learn the different sounds and when alarms keep occurring repeatedly, the biggest question to ask is why? First and there something wrong with the patient? Maybe he's tachycardic becase he has a fever. Is there a problem with how the equipment is set up? Perhaps there is water that has accumulated in the ventilator tubing. Then, is the equipment faulty? Try using a new pulse oximeter and send the other to be checked.

    These are just examples of some trouble-shooting steps that we can take. Here's a link to some more information from the American Journal of Critical Care:

  3. From my experience this problem of alarm fatigue is very much multi-faceted. I definitely agree with your statement that there needs to be a "review of the technology that is making the alarm happen, AND review the process of who is getting what alarm when and why". But this problem is much more difficult to solve.

    This is already a very well studied problem by organizations like the ACCE and AAMI. Rather than try to explain all this here, I encourage you to read this paper published by the ACCE a number of years ago. This paper ( is actually very eye opening as to the complexity and scope of the problem. There has been a lot of progress and there are many standards in place already for medical device alarms. But some of these standards have not been adopted by the device manufacturers or vendors are not forced to comply - so this remains an issue. The paper talks about this aspect.

    But aside from the medical devices, as Kourtney mentions, there is still the clinical environment that is chaotic and nurses work in a very interrupt driven environment. I believe that technologies that target improved clinical communications (caregiver to caregiver for example) will help and alarm management systems will also assist with reducing the overall interrupts and sheer number of alarms. Alarms will never go away - but how nurses deal with them can definitely be improved with existing technologies commercially available today.

  4. This is the challenge we all face around technology...the more we connect the more we introduce challenges and problems which MUST be addressed or we've just created another technology tax. Automation and integration must be married to workflow if we are going to yield the right benefits to both the caregiver and patient...otherwise we are just connecting. More than managing the alarm we have to think about ownership of the alarm event...there is a rethink required as we seek to improve this ecosystem. More than alarm fatigue it becomes technology fatigue.

    It begins with a comprehensive approach in the design and delivery of a cover workflow, technology and outcomes. It goes beyond connectivity.

    You captured the heart of the issue...this is about people, about life, about an opportunity to prevent and compliment what drives those who deliver direct care every day.

    Nice post Kourtney!


Thanks for Posting on Clinical Transformation!

Kourtney Govro