Ten years later, alarm fatigue is still a safety concern.

Kimberly Albanowski; Kendall J Burdick; Christopher P Bonafide; Ruth Kleinpell; Joseph J Schlesinger

Commentary

Ten years later, alarm fatigue is still a safety concern.

September 20, 2023

Albanowski K, Burdick KJ, Bonafide CP, et al. AACN Adv Crit Care. 2023;34(3):189-197.

View more articles from the same authors.

Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid or nonactionable, and thus fail to respond or respond more slowly to actionable alerts. The article describes the progress made in reducing nonactionable alarms and making actionable alarms more useful to responding clinicians. Clinical approaches include customization of alert parameters to reduce nonactionable alarms, while engineering solutions include reducing the volume or adjusting the tone of auditory alerts.

PubMed citation

Available at

Related Resources From the Same Author(s)

Observing sources of system resilience using in situ alarm simulations.

October 25, 2023

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial.

March 2, 2022

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

July 13, 2011

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.

January 27, 2016

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

November 15, 2023

Secure text messaging in healthcare: latent threats and opportunities to improve patient safety.

October 30, 2019

Optimization of drug–drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard.

December 10, 2014

Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital.

April 29, 2015

Cost-benefit analysis of a medical emergency team in a children's hospital.

August 20, 2014

Physician attitudes toward family-activated medical emergency teams for hospitalized children.

April 2, 2014

Impact of rapid response system implementation on critical deterioration events in children.

November 13, 2013

Development of a pragmatic measure for evaluating and optimizing rapid response systems.

March 29, 2012

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

April 19, 2017

Technological distractions—part 1 and part 2.

February 14, 2018

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.

January 15, 2020

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

December 19, 2018

An official Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action.

July 27, 2016

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

Recovery from medical errors: the critical care nursing safety net.

January 31, 2006

Effect of reducing interns' work hours on serious medical errors in intensive care units.

March 27, 2005

Changes in medical errors after implementation of a handoff program.

November 12, 2014

I-PASS mentored implementation handoff curriculum: champion training materials.

March 13, 2019

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Effect of genetic diagnosis on patients with previously undiagnosed disease.

November 7, 2018

Safety competency: exploring the impact of environmental and personal factors on the nurse's ability to deliver safe care.

October 19, 2022

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care.

March 17, 2021

Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.

June 14, 2023

Hospital readmissions: physician awareness and communication practices.

November 19, 2008

Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety.

July 19, 2023

A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals.

March 7, 2018

Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review.

July 26, 2017

International evaluation of an AI system for breast cancer screening.

January 29, 2020

Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011.

May 25, 2016

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey.

February 12, 2020

Liquid medication errors and dosing tools: a randomized controlled experiment.

October 5, 2016

Pictograms, units and dosing tools, and parent medication errors: a randomized study.

July 19, 2017

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

May 31, 2017

Diagnostic concordance among pathologists interpreting breast biopsy specimens.

March 25, 2015

Effect of pharmacist counseling intervention on health care utilization following hospital discharge: a randomized control trial.

June 8, 2016

Safety and diagnostic accuracy of tumor biopsies in children with cancer.

June 10, 2015

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

August 24, 2011

Wide heart monitor use tied to missed alarms.

January 18, 2012

Simulation-based medical error disclosure training for pediatric healthcare professionals.

September 26, 2007

Americans' growing exposure to clinician quality information: insights and implications.

March 20, 2019

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference.

November 28, 2012

Readiness of US general surgery residents for independent practice.

October 4, 2017

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis.

September 13, 2023

Improving handoffs in the emergency department.

October 28, 2009

Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.

October 10, 2012

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Preventing harm in the ICU—building a culture of safety and engaging patients and families.

July 12, 2017

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

July 19, 2017

What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process.

March 6, 2024

Simulating for quality: a centralized quality improvement and patient safety simulation curriculum for residents and fellows.

June 1, 2022

A team-based approach to reducing cardiac monitor alarms.

November 26, 2014

Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.

November 11, 2009

Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization.

November 15, 2023

Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy.

February 5, 2020

Identifying and reconciling patients' allergy information within the electronic health record.

July 6, 2022

Association of patient and family reports of hospital safety climate with language proficiency in the US.

June 29, 2022

Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises.

April 29, 2020

Reasons provided by prescribers when overriding drug–drug interaction alerts.

November 28, 2007

Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: a consensus panel report.

April 3, 2019

To expand the evidence base about harms from tests and treatments.

September 15, 2021

Expert consensus on currently accepted measures of harm.

September 9, 2020

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Referrals of infection control breaches to public health authorities: ambulatory care settings experience, 2017.

September 23, 2020

Diagnostic accuracy of a large language model in pediatric case studies.

January 17, 2024

Engaging hospital patients in the medication reconciliation process using tablet computers.

September 26, 2018

Infection control assessment of ambulatory surgical centers.

June 23, 2010

Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program.

July 19, 2017

Every error a treasure: improving medication use with a nonpunitive reporting system.

July 18, 2007

Validation of a diagnostic reminder system in emergency medicine: a multi-centre study.

October 17, 2007

I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources.

March 10, 2019

Systematic review of malpractice litigation in the diagnosis and treatment of acute stroke

October 9, 2019

Preventability and causes of readmissions in a national cohort of general medicine patients.

May 4, 2016

Decreasing handoff-related care failures in children's hospitals.

August 13, 2014

Safety of overlapping inpatient orthopaedic surgery: a multicenter study.

January 16, 2019

Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.

December 11, 2013

Adverse events in hospitalized pediatric patients.

July 25, 2018

Effect of computer order entry on prevention of serious medication errors in hospitalized children.

March 19, 2008

The effect of drug concentration expression on epinephrine dosing errors: a randomized trial.

January 16, 2008

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

April 15, 2005

Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.

March 27, 2005

The costs of adverse drug events in hospitalized patients.

March 27, 2005

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

March 27, 2005

Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic.

October 7, 2020

Family safety reporting in medically complex children: parent, staff, and leader perspectives.

July 6, 2022

Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans — Los Angeles, California, 2020.

June 10, 2020

Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment.

December 5, 2018

Safety culture in cardiac surgical teams: data from five programs and national surgical comparison.

September 23, 2015

Variation in printed handoff documents: results and recommendations from a multicenter needs assessment.

June 10, 2015

A trigger tool to detect harm in pediatric inpatient settings.

June 3, 2015

Clinical decision support for atypical orders: detection and warning of atypical medication orders submitted to a computerized provider order entry system.

June 25, 2014

Related Resources

Assessing the impact of real-time random safety audits through full propensity score matching on reliable data from the clinical information system.

March 20, 2024

Learning from non-routine events and teamwork in intensive care units: challenges and opportunities.

February 28, 2024

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

February 14, 2024

WebM&M Cases

Medication Mix-Up Leads to Patient Death

November 30, 2023

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

November 15, 2023

Supporting nurses in acute and emergency care settings to speak up.

November 8, 2023

Impact of hospital-acquired pneumonia on the Medicare program.

November 8, 2023

Observing sources of system resilience using in situ alarm simulations.

October 25, 2023

Battling alarm fatigue in the pediatric intensive care unit.

October 11, 2023

Work system barriers and facilitators of a team health information technology.

September 13, 2023

In-situ simulations to detect patient safety threats during in-hospital cardiac arrest.

September 13, 2023

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

September 6, 2023

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century.

August 23, 2023

WebM&M Cases

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

July 31, 2023

Anticoagulation-associated adverse drug events in hospitalized patients across two time periods.

July 26, 2023

Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success.

July 19, 2023

WebM&M Cases

Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.

June 28, 2023

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States.

June 21, 2023

The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study.

June 14, 2023

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

March 22, 2023

Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future.

March 15, 2023

Undertaking risk and relational work to manage vulnerability: acute medical patients' involvement in patient safety in the NHS.

March 15, 2023

Paediatric family activated rapid response interventions; qualitative systematic review.

January 18, 2023

Journal Article

Commentary

Critical care resource nurse team: a patient safety and quality outcomes model.

November 16, 2022

Algorithm that detects sepsis cut deaths by nearly 20 percent.

August 24, 2022

See More About The Topic

Hospitals

Intensive Care Units

Critical Care Nursing

Alert fatigue

Technologic Approaches

Ten years later, alarm fatigue is still a safety concern.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Critical care resource nurse team: a patient safety and quality outcomes model.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Ten years later, alarm fatigue is still a safety concern.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Critical care resource nurse team: a patient safety and quality outcomes model.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site