Sentinel Event Alert Issue 50¶
The Joint Commission. (2013). Sentinel Event Alert Issue 50: Medical Device Alarm Safety in Hospitals.
Cited by¶
8 citations across 8 artifacts.
Each citation links to the sentence it supports in the citing article.
Domain-specific¶
- Alarm Fatigue
- These findings drove the U.S. Joint Commission to issue Sentinel Event Alert #50 on medical-device alarm safety in 2013
Supported in partVerified against the source
- These findings drove the U.S. Joint Commission to issue Sentinel Event Alert #50 on medical-device alarm safety in 2013
- Operator-Vigilance Dependency
- After patient deaths linked to silenced or missed alarms, the U.S. Joint Commission issued a Sentinel Event Alert on alarm safety (2013)
SupportedVerified against a saved copy of the source
“Sentinel Event Alert 50: Medical device alarm safety in hospitals”
- After patient deaths linked to silenced or missed alarms, the U.S. Joint Commission issued a Sentinel Event Alert on alarm safety (2013)
- Public-Warning Fatigue
- Nurses habituate and response to true, life-threatening alarms slows or is missed, with documented deaths
SupportedVerified against the source
- Nurses habituate and response to true, life-threatening alarms slows or is missed, with documented deaths
Mechanisms¶
- Alert Fatigue Dashboard
- An intensive-care unit is drowning in alarms — cardiac monitors, infusion pumps, ventilators — and alarm fatigue is a recognized patient-safety hazard.
This sourceIdentifies alarm fatigue from the multitude of ICU device alarms—including monitors, pumps, and ventilators—as a recognized patient-safety hazard.
- An intensive-care unit is drowning in alarms — cardiac monitors, infusion pumps, ventilators — and alarm fatigue is a recognized patient-safety hazard.
- Alert Threshold and Escalation
- Its failure mode is alert fatigue: thresholds set too sensitively, or an escalation ladder that pages for every blip, train responders to dismiss alerts — so the one page that mattered is muted along with the hundred that did not.
This sourceExplains that excessive or overly sensitive alarms desensitize responders and can cause important alarms to be ignored or missed.
- Its failure mode is alert fatigue: thresholds set too sensitively, or an escalation ladder that pages for every blip, train responders to dismiss alerts — so the one page that mattered is muted along with the hundred that did not.
- Attention Cap Management
- Its trigger is the saturation signal of ignored or missed alerts, the sign the receiver has already gone numb.
This sourceWarns that high volumes of mostly non-actionable alarms desensitize clinicians, causing ignored alarms and missed clinically significant events.
- Its trigger is the saturation signal of ignored or missed alerts, the sign the receiver has already gone numb.
- Exception Alert Priority Table
- Its failure mode is the exception flood: if too many conditions are licensed to interrupt, or thresholds are set too low, the receiver drowns in overrides and begins to ignore them — the well-documented pattern of alarm fatigue, in which excessive alerts desensitize people so that critical ones are missed or silenced.
This sourceIdentifies excessive and poorly managed device alarms as producing alarm fatigue, desensitization, missed signals, and failures to respond.
- Its failure mode is the exception flood: if too many conditions are licensed to interrupt, or thresholds are set too low, the receiver drowns in overrides and begins to ignore them — the well-documented pattern of alarm fatigue, in which excessive alerts desensitize people so that critical ones are missed or silenced.
- Fault Detection and Diagnosis
- Tuned too sensitive, it drowns operators in false alarms until they stop trusting it — alarm fatigue, where a flood of low-value alerts trains people to ignore the one that matters.
This sourceExplains that overly sensitive, low-value alarms create alarm fatigue and can train responders to miss or ignore an important alarm.
- Tuned too sensitive, it drowns operators in false alarms until they stop trusting it — alarm fatigue, where a flood of low-value alerts trains people to ignore the one that matters.
Verification¶
Does it exist? Not checked yet. This entry carries no identifier to resolve. It was extracted from the citation as written in the article, normalized, and deduplicated against the rest of the registry.
Does it back the claim? Read against the text for 3 of 8 citations: 2 supported, 1 supported in part. Each verdict is shown under its citation below, with what in the work backs the sentence.
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Links previously used in the corpus¶
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