Alarm Fatigue Causal Factors
1. Lack of consistent understanding of PCA monitors and alarms led to a failure to
monitor and trend low respiratory rate alarms and consider decreased narcotic
administration.
2. Lack of standard work for staff to review the monitor screen displaying respiratory
trends (total PCA dose, EtCO2 and respiratory rate) when responding to alarms.
When in the room, staff did not access the capnography monitor as a way to
assess the patient’s respiratory status. The end tidal CO2 (EtCO2) trending
function is not well understood or used by nursing or respiratory care. Either of
these trends indicates the need to assess the patient’s sedation level and
consider decreasing the narcotic administration. Although vital signs are
monitored every 2 hours while on PCA, the policy did not include viewing and
documenting trend data.
3. Staff can sometimes consider capnography alarms to be nuisance alarms and
may disregard without an adequate assessment (e.g., trending respiratory data)
or without notifying others of the need to respond. Alarm fatigue can occur when
the patient is able to be aroused for several previous alarms. Multiple staff
members can reset the patient’s alarm to simply silence it. This includes nurses,
aides, other disciplines (RT, PT, etc.). Family members could reset alarms after
watching staff.
4. The alarms do not sound at the nurses’ station and are not connected to a
central monitor; therefore, staff may not have been able to hear the alarms when
away from the patient’s room. The alarms could be sent to phones, but due to
concern about nuisance alarms this was not implemented. If the monitor senses
low respiratory rate, it beeps. If the patient awakes and self corrects (increases
their breathing), the alarm resets on its own. This alarm functionality may reduce
awareness of the frequency that the alarms are sounding.
5. It is possible that there was drug administration by proxy. There were significantly
more drug attempts than actual drug delivery. There was no documentation of
PCA education with the family– which does include instructions regarding the
danger of others pushing the PCA button.
Tips for Preventing Accidental Opioid Overdose
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Hospital leaders and staff need to understand that opioid analgesics rank among
the drugs most frequently associated with adverse drug events.
Effective processes for assessing and managing pain to avoid accidental opioid
overdoses need to be in place. Processes should include ongoing clinical
monitoring of patients receiving opioid therapy by performing serial assessments
of the quality and adequacy of respiration. When designing effective processes,
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consider resources such as the American Society for Pain Management Nursing
Guidelines on Monitoring for Opioid Induced Sedation and Respiratory
Depression (2011).
Consider standardized template for hand-offs to improve communication
between nurses.
Track and analyze opioid-related incidents for quality improvement purposes.
Use safe technology such as PCA pumps to control dosing; use monitoring
devices to assess for respiratory status changes signaling over-sedation.
Provide appropriate education and training to staff, patients and families about
the safe use of opioids.
Remind staff of the importance of “critical thinking” when administering opioids to
patients.
Source: The Joint Commission (2012)
Tips for Managing Alarm Fatigue
Establish guidelines for tailoring alarm settings and alarm limits for specific
patients. Not all patients will require the same alarm parameters.
Inventory all alarms in high-risk areas to assure alarms are working properly;
assess for probability of alarm fatigue.
Inspect, check, and maintain alarm-equipped medical devices and base
frequency of alarms on criteria such as manufacturer recommendations, risk
level of the patient, etc.
Identify situations when alarm signals are not clinically necessary and remove
them.
Ensure hospital leaders understand the extent to which alarm fatigue is occurring
in the organization. Without an awareness of the problem, no solutions can be
put in place. Observation and open-communication can facilitate a better
understanding of the problem.
Everyone working in a clinical environment should go through alarm training
including what alarms are in use and why. Emphasize that silencing alarms is
NOT to be a routine practice without an adequate assessment of the patient’s
condition completed by qualified staff.
Ensure staff has a systematic way to report equipment malfunctions including
equipment where alarms are not providing appropriate alerts (alarming without
clinical cause). If staff does not trust that the alarms are working properly, they
may tend to ignore the sound.
Because alarm sounds are not standardized, assure staff knows how to
differentiate the sounds designed to inform them of a potential patient condition
change (Oxygen monitor) or potential for risk (fall alarm).
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Assess monitoring system for best positioning – central monitoring vs. in the
room only?
 Educate patients and families about drug tolerance, expectations concerning
pain, the purpose of various alarms, including the alarm sounds so they can alert
staff when an alarm goes off. Teach patients and families to report alarms rather
than how to silence them.
Source: The Joint Commission (2013)
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