**7. Potential outcomes of alarm fatigue**

Significant percentage of nonactionable alarms in the typical modern clinical environment can lead to the development (and subsequent habituation) of AF. As previously mentioned, AF can be characterized by alarm desensitization, mistrust of alert accuracy/utility, and delay of caregiver response (or even lack thereof). Commonly seen reactions to AF include the deactivation and silencing of systems or adjustment of alarm parameters to decrease the number of alarms. Such reactive behaviors have the potential to result in missed critical alarms, leading to patient morbidity or even mortality. In fact, patient safety considerations associated with AF are among the top items of Emergency Care Research (ECRI) Institute's Health Technology Hazards list [77, 78]. The subject of AF has been extensively studied, primarily due to its high prevalence across essentially all health-care settings. The underreporting of alarm-related events has been recognized as a challenge, and it should be noted that recorded incidents likely reflect only a small proportion of actual events. Available records from the Joint Commission's Sentinel Event Database show 98 alarmrelated occurrences between January 2009 and June 2012 (**Figure 4**). Of these reported events, several common alarm system issues (**Figure 5**) were directly connected to events leading to injury or death (**Table 1**) [79].

**Figure 3.** The word cloud demonstrating the multifaceted phenomenon of alarm fatigue.

decreased alarm response and task performance [8].

**7. Potential outcomes of alarm fatigue**

fields (**Figure 3**).

102 Vignettes in Patient Safety - Volume 4

effort of acknowledging, evaluating, and responding to an alarm significantly increases the overall time commitment and workload of the nurses, which further perpetuates the trend of

Because multiple factors contribute to AF, many existing models struggle to fully account for (and address) clinician behavioral patterns seen with AF [75]. At the same time, it should be noted that AF is not unique to clinicians. In fact, a similar phenomenon has also been seen among human operators utilizing automated monitoring systems, such as aircraft pilots and nuclear power plant operators. The excessive number of alarm activations leads to the tendency of operators to ignore alerts, particularly when the monitoring system produces a high rate of false alarms or alerts [75]. For these operational environments, it has also been suggested that increased primary and secondary task workloads have a compounding effect on alarm response degradation that may occur in the setting of low alarm system reliability [76]. Similar to the clinical setting, AF can be associated with serious safety risks and represents a similar barrier to the practical application of automated monitoring systems in other

Significant percentage of nonactionable alarms in the typical modern clinical environment can lead to the development (and subsequent habituation) of AF. As previously mentioned, AF can be characterized by alarm desensitization, mistrust of alert accuracy/utility, and delay of caregiver response (or even lack thereof). Commonly seen reactions to AF include the deactivation and silencing of systems or adjustment of alarm parameters to decrease the number of alarms. Such reactive behaviors have the potential to result in missed critical alarms, leading to patient morbidity or even mortality. In fact, patient safety considerations associated with AF are among the top items of Emergency Care Research (ECRI)

**Figure 4.** Alarm-related events and subsequent results from January 2009 to June 2012 (source: Joint Commission's Sentinel Event Database).

**Figure 5.** Major contributing factors of alarm-related events (source: Joint Commission's Sentinel Event Database).


it is important to ensure adequate staff education, equipment training, and closer team collaboration to improve patient safety within the existing framework [8, 85]. In addition to staff education, hospital policies have been developed and implemented to more clearly define which staff members are able to change alarm settings, as well as how such changes should be made and documented. Many of these polices have also delegated the responsibility of performing clinical alarm monitoring rounds to a staff member in order to allow for continued

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To address the issues of staff workload, two potential approaches have been proposed. The first approach consists of secondary notification systems. The second option involves the use of dedicated staff to oversee alarms. A secondary notification system involves a specialized network interface that algorithmically facilitates the decision process regarding which alarms will be further communicated or escalated to pertinent downstream clinical staff. Further, this system would also enable the automatic escalation of an alert to another clinician, should the primary recipient fail to acknowledge the alarm within a designated timeframe. The use of staff to oversee alarms, while an expensive option, can give additional support to care providers in the form of dedicated personnel whose responsibility is to continuously monitor patient

No matter the solution, all the quality improvement processes require a multidisciplinary approach to address the causes and effects of AF. Only through collaborative efforts can substantial change be accomplished to reduce the number of alarm-related events in health care. In addition to the quality improvement measures taken by hospitals, technological advances have also led to more efficient and practical application of patient monitors in the clinical setting. These advances are directed at the reduction of nonactionable alarms with the goal of decreasing the alarm desensitization associated with AF. The importance of adequate information technology support, including better device designs, must be emphasized. As increasingly efficient and complex monitoring equipment is introduced into the clinical realm, certain phenomena, such as the emergence of "unpredictable code," may adversely affect computer performance (including the ability to effectively recognize important data patterns) and lead to clinical alerts being missed despite the fact that alert-specific data were clearly and

In general, clinical monitoring is based on a careful balance between sensitivity and specificity of alarm signal recognition, as well as the associated threshold setting required to trigger "alert condition" [90, 91]. Increasing monitor sensitivity helps ensure that truly significant events are not missed, primarily using single-parameter alarms and default thresholds [8]. However, as a trade-off this increases the incidence of nuisance alarms that are nonactionable. This issue may be remedied by the development of "smart alarm systems" that use algorithmic approaches to evaluate multiple parameters prior to determining whether the detected change is truly critical, and only then sending an alert to the operator [15]. This improvement in device specificity would result in significantly fewer false alarms and therefore reduce

review of the application of patient monitoring systems [86–88].

data trends and alarms from a central station [58].

**9. Technological advances in patient monitors**

provably present [89].

**Table 1.** Common alarm-related events leading to injuries or deaths.

Additionally, the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database has identified 566 alarm-related patient deaths between January 2005 and June 2010 [79]. Reports detailing alarm-related events have prompted thorough investigation into AF and possible strategies to address this important phenomenon in the clinical setting.
