• What Causes Alarm-Related Adverse Incidents?

    May 25, 2012

    Alarm-related adverse incidents may result from a variety of factors:

    • Alarm fatigue, in which staff become overwhelmed by the sheer number of alarms
      • This can result in alarm desensitization, which in turn can lead to missed alarms or delayed alarm response
      • Consequently, staff may take inappropriate steps such as:
        • Improperly adjusting alarm limits outside the safe and appropriate range for a particular patient in an attempt to reduce the number of alarms
        • Turning down the volume of alarms to an inaudible level in an attempt to reduce alarm fatigue and reduce stress on the patient and family
        • Staff being unable to distinguish the urgency level of alarms or tell which device an alarm is coming from
        • Monitors and alarms not being restored to the active setting after being put on standby (e.g., while the patient has left the floor for testing)
        • Alarms not being properly relayed to ancillary notification systems (e.g., paging system, wireless phones), potentially leading to a failure to notify relevant staff
        • A lack of adequate alarm-notification and alarm-response protocols
        • Failure to promptly troubleshoot and correct leads-off alarms or frequent nuisance alarms caused by artifact 

    Return to related Leadership article: Device Alarms: Ensuring They Help, Not Hurt