Joint Commission issues Sentinel Event Alert on medical device alarm safety

Patient Safety Monitor Insider

April 10, 2013

The Joint Commission issued a Sentinel Event Alert on April 8 warning hospitals against alarm fatigue caused by medical devices. According to the alert, thousands of alarm signals occur in each hospital unit, each day, and an estimated 85% – 99% of the signals do not require clinical intervention. Clinicians consequently become overwhelmed, as well as desensitized to the sounds, and suffer from alarm fatigue. When clinicians then turn off alarms, reduce the volume, or readjust the settings, patient safety is compromised.

The Joint commission reports that nearly 100 alarm-related events occurred in the period between January 2009 and June 2012. Of these events, 80 resulted in death, 13 in permanent loss of function, and five in unexpected additional care/extended stay.

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