Joint Commission Releases Sentinel Event Alert on Alarm Hazards

June 1, 2013 | Evaluations & Guidance


When clinicians become desensitized or immune to the constant alarming of devices in the healthcare setting, the result can be missed alarms. This problem, known as alarm fatigue, is one of the concerns addressed in a recent Joint Commission Sentinel Event Alert, which provides guidance to healthcare workers on how to improve alarm safety.

The problem of alarm fatigue is compounded by the large percentage of alarms that do not require clinical intervention—estimated by the Joint Commission at anywhere from 85% to 99%. These alarms occur when, for example, a device’s default settings are not adjusted for the patient, alarm limits are set too tightly, electrocardiogram electrodes are dried out, or sensors are improperly positioned. In attempting to reduce the disruptions caused by alarms, clinicians may act in ways that can endanger patients. For example, they may turn down the volume of the alarm, turn the...

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