Advances in computerized technology provide health care professionals with enhanced capability to monitor a wide variety of patient conditions and, hopefully, prevent adverse events.  However, with that comes a multitude of alerts, alarms and – in the case of ventilators and cardiac monitors – a cacophony of noise and flashing lights.  This has led to a phenomenon known as “alert fatigue”, which is becoming increasingly common among health care professionals – sometimes with disastrous consequences.

There was a recent news story about two British Columbia pharmacists who were found to have deliberately turned off certain “compatibility warnings” on their pharmacy’s computer system[1].  These warnings are intended to alert the dispensing pharmacist to any potential adverse drug interactions, but can result in a number of “false alarms” for harmless interactions.  In this particular situation, however, a patient was given two different medications that were incompatible to one another and she subsequently died from a severe bacterial infection resulting in complete respiratory failure.

In our technology dependant health care system, “alert fatigue” among practitioners is a well-documented and increasingly concerning problem.  Between 2005 and 2008, the Food and Drug Administration in the U.S. reported 566 alarm-related deaths[2].  Alerts are meant to warn care providers that something is wrong and that action needs to be taken, but frequently the cause of the alarm is not clinically relevant to the patient.  This can all too often make an alarm seem to be nothing more than an annoyance and a distraction that disrupts workflow.  The danger in of this, of course, is that practitioners will miss or ignore a potentially critical alert – or even intentionally change an alarm parameter to reduce the likelihood that it will activate.

It can be very challenging for RTs to remain vigilant so that they can attend to what is truly important among all the ringing, chirping, beeping and flashing.  The first step to preventing “alert fatigue” is to acknowledge that it is a very real problem and to watch for signs that you may be falling victim to it. The next step is to engage your organization’s support in combating this threat to patient safely by developing specific policies and procedures on alarm settings, delay ranges and customizing alarms based on the patient’s needs[3].  In addition, careful consideration of the alarm capabilities of equipment at the time of purchase has been shown to go a long way to mitigate “alert fatigue”.

 

[1] Tomlinson, K. (2014, October 6). PT Pharmacists’ failure to check drug risks leads to ‘horrible’ death

B.C. woman’s demise exposes dangers of ‘alert fatigue’ among pharmacists. Canadian Broadcasting Corporation. Retrieved from http://www.cbc.ca/news/canada/british-columbia/pharmacists-failure-to-check-drug-risks-leads-to-horrible-death-1.2787185

 

[2] Rodak, S. (2012, February 15). Sounding the Alarm: 6 Strategies to Reduce, Prevent Alarm Fatigue. Becker’s Infection Control & Clinical Quality. Retrieved from http://www.beckersasc.com/asc-quality-infection-control/sounding-the-alarm-6-strategies-to-reduce-prevent-alarm-fatigue.html

 

[3] Cvach, M. (2012). Monitor alarm fatigue: an integrative review. Biomedical Instrumentation & Technology, 46(4),   268-277.