CHICAGO — Constantly beeping alarms from devices that monitor the vital signs of the critically ill have “desensitized” hospital workers who sometimes ignore the noise, leading to at least two dozen deaths a year on average, a hospital accrediting group said Monday.
And these cases are probably vastly underreported, said the Joint Commission in an alert to hospitals calling attention to the problem. The beeping devices include those that measure blood pressure and heart rate among other things. Some beep when there’s an emergency, and some beep when they’re not working. That can lead to noise fatigue and the delay in treating a patient can endanger lives, the accreditation commission says.
Complicating the situation is the abundance of technology, with no standardization for what the beeps mean, said Dr. Ana McKee, the commission’s executive vice president and chief medical officer.
The commission’s estimate of possible deaths related to the problem is considerably lower than the reports it found in a U.S. Food and drug Administration database. The FDA lists more than 500 deaths potentially linked with hospital alarms between January 2005 and June 2010. But that includes mandatory reports of malfunctions and in some cases the connection to a death is only tenuous. The commission’s own database reports 80 deaths and 13 severe injuries between January 2009 and June 2012. Hospitals voluntarily report these to the commission, which reviews them and in these cases determined there was a clear connection to the device, said McKee.
There likely are far more problems than have been reported, partly because ignoring or misinterpreting an alarm may have set off a chain of events that led to an injury or death, she explained. But tracing back to that first oversight can be difficult, McKee said.
Alarm-system events included patient falls, delays in treatment and medication errors that resulted in injury or death, the Joint Commission said.
The most common factor was “alarm fatigue.” But other problems included misinterpreting alarm signals, too few staffers to respond to alarms, and equipment malfunctions.
“With the proliferation of technology, alarms, and a lack of standardization,” it’s more challenging for doctors and nurses to respond adequately, McKee said. The commission said hospital leaders need to address the problem and train staffers in safe alarm management.
The organization accredits more than 10,000 U.S. hospital and health care organizations. Hospitals covet accreditation and following commission advice is key to maintaining it.
McKee said the alert will help raise awareness and lead to hospital changes that may save lives.
Online: Commission: http://www.jointcommission.org