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Copyright 2014 American Nephrology Nurses' Association
Horkan, A.M. (2014). Alarm fatigue and patient safety. Nephrology Nursing Journal, 41(1), 83-85. Retrieved fromhttp://www.prolibraries.com/anna/?select=session& sessionID=2975
Key Words: Alarm fatigue, patient safety, medical errors, false alarms, nuisance alarms.
A 36-year-old female receives hemodialysis through a right forearm arteriovenous fistula (AVF). The nurses working in the hemodialysis unit are busy administering medications and preparing for the next shiftof patients. Machine alarms have been sounding intermittently on various patients throughout the shift. The female patient's venous pressure alarm is triggered, and her nurse promptly resets the alarm and returns to her previous task. The venous pressure alarm continues to be triggered with nurses resetting the alarm three separate times. The fourth time the alarm sounds and the nurse responds, the patient complains of pain in her right arm. The nurse assesses the access arm and discovers severe edema of the right forearm from an infiltration of the venous needle. Due to the severity of the infiltration, treatment is stopped. The patient's blood cannot be returned, which leads to a drop in the patient's hemoglobin and the patient requiring the placement of a temporary central venous catheter for dialysis while swelling associated with infiltration resolves. One may question: Did alarm fatigue contribute to compromising the safety of this patient?
Over the past two decades, medical errors occurring within healthcare organizations have increased with the resultant consequences ranging from minor to catastrophic for healthcare recipients (Edwards & Furlan, 2010; Hutter, 2008; James, 2013). Alarm fatigue is increasingly being identified as a patient safety issue.
The Joint Commission, the American Association of Critical-Care Nurses (AACN), the Food and Drug Admi - nistration (FDA), the ECRI Institute, and the Association for the Advancement of Medical Instrumentation (AAMI) have all identified the need to address alarm management and alarm fatigue. In 2011, AAMI convened a Medical Device Alarms Summit, and after the summit, created an alarm best practices workgroup to address the problem of clinical alarm fatigue. In 2012, 2013, and 2014, the ECRI Institute identified clinical alarm hazards as the top potential danger area in hospitals and health systems (ECRI, 2013). In 2013, The Joint Commission issued a sentinel event alert on alarm-related events, citing 98 clinical alarm-related events that were reported between 2009...