Medical Device Alarm Safety in Hospitals

The Joint Commission. (2013). Medical Device Alarm Safety in Hospitals. Sentinel Event Alert.

Type

Report

Intellectual base

Grey literature

Year

2013

Link

https://www.jointcommission.org/en-us/knowledge-library/newsletters/sentinel-event-alert/issue-50

Cited by

5 citations across 5 artifacts.

Each citation links to the sentence it supports in the citing article.

Mechanisms

• Alert Frequency Adjustment
  • The result is hundreds of alarms per bed per day, the overwhelming majority clinically meaningless, and nurses grow desensitized — the dangerous phenomenon of alarm fatigue, flagged by The Joint Commission as a patient-safety hazard.

    This sourceReports several hundred alarms per patient per day and identifies alarm fatigue as a serious patient-safety hazard highlighted by The Joint Commission.

• Algorithmic Escalation Gate
  • Its characteristic failure is alarm fatigue.

    This sourceIdentifies alarm fatigue as a leading contributor to alarm-related sentinel events in hospitals.

• Multimodal Redundant Encoding
  • Pile cues onto every channel and receivers habituate — the desensitisation known as alarm fatigue

    This sourceDefines alarm fatigue as desensitization caused by excessive alarm exposure.

• Out-of-Domain Prompt
  • Its signature failure is alert fatigue

    This sourceDescribes alarm fatigue as clinicians becoming desensitized and failing to respond when exposed to a high volume of mostly non-actionable alarms.

• Secondary-Resource Telemetry
  • And a monitor decays into alarm fatigue

    This sourceDescribes alarm fatigue caused by excessive non-actionable or false alarms, which can desensitize operators and prompt unsafe adjustment or disabling of alarm settings.

Verification

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Links previously used in the corpus

Before the registry existed this work was also linked 1 other way.

• https://www.jointcommission.org/en/knowledge-library/newsletters/sentinel-event-alert/issue-50 ×1

Registry ID ref:081b6c0c045b · see in the full table