The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
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.
Khan A, Karavite DJ, Muthu N, et al. J Patient Saf. 2023;19:251-257.
For incidents to be properly addressed, incident reports must be appropriately identified and categorized by safety managers. This study compared the categorization of incidents as involving health information technology (HIT) or not involving HIT by specialists trained in HIT and patient safety and safety managers trained in traditional methods of health safety. Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents involving or not involving HIT, respectively. Increased education for safety managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents.
Bonafide CP, Miller JM, Localio AR, et al. JAMA Pediatr. 2019;174:162-169.
… subsequent medication errors (based on barcode alerts) in a pediatric ICU. Medication administration errors were more … have become accustomed to their frequent occurrence. … Bonafide CP, Miller JM, Localio AR, et al. Association … interruptions and medication administration errors in a pediatric intensive care unit. JAMA Pediatr [epub ahead of …
Hagedorn PA, Singh A, Luo B, et al. J Hosp Med. 2020;15:378-380.
Secure text messaging has emerged as one method to improve communication between providers and nurses. This paper discusses concerns over alarm fatigue, communication errors and omitting critical verbal communication and provides proposed solutions to support appropriate and effective use of text messaging in a healthcare setting.
Wright A, McEvoy D, Aaron S, et al. J Am Med Info Asso. 2019;26:934-942.
… interaction alerts and reasons they were overridden across a variety of electronic health records from 10 different … DS; Aaron S; McCoy AB; Amato MG; Kim H; Ai A; Cimino JJ; Desai BR; El-Kareh R; Galanter W; Longhurst CA; Malhotra S; Radecki RP; Samal L; …
Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Crit Care Med. 2017;45:1481-1488.
These paired systematic reviews examined alert fatigue in the intensive care unit. The first systematic review found several strategies to reduce alerts including prioritizing alerts, developing multipart rules instead of simple alerts, and customizing commercial platforms with end-user input. The second systematic review found that alarm best practices from high reliability industries are not adhered to in intensive care unit settings.
Bedside monitors alert nurses to clinical deterioration. This prospective observational study examined nurse responses to bedside physiologic monitors. The mean response time was over 10 minutes. Less than 1% of alarms were actionable, underscoring the importance of addressing alarm fatigue.
Paine CW, Goel V, Ely E, et al. J Hosp Med. 2016;11:136-144.
Alarm safety is now a Joint Commission National Patient Safety Goal. This systematic review analyzed 24 studies on alarm characteristics and 8 studies that evaluated interventions to improve alert fatigue. Consistent with other studies, the vast majority of the time, alarms do not signal problems that require clinician action. The most promising intervention strategies for reducing alarms that have emerged thus far are widening alarm parameters, implementing alarm delays, and frequently changing telemetry electrodes and wires. A PSNet perspective discussed approaches to reduce alert fatigue while maintaining safety.
Bonafide CP, Lin R, Zander M, et al. J Hosp Med. 2015;10:345-51.
… intensive care settings. This direct observation study of a pediatric intensive care unit found that response times … were more preceding nonactionable alarms, demonstrating a delay in alarm response due to alarm fatigue . This finding …
Simpao AF, Ahumada LM, Desai BR, et al. J Am Med Inform Assoc. 2015;22:361-9.
Researchers used rapid-cycle iterative interventions to improve drug interaction alerts by eliminating clinically irrelevant notifications. These efforts resulted in fewer alerts and fewer manual overrides of alerts without any serious safety events, emphasizing the often cited need to streamline clinical decision support to prevent alarm fatigue.
Bonafide CP, Localio R, Song L, et al. Pediatrics. 2014;134:235-41.
… clinical deteriorations. This study aimed to create a financial model to determine the potential benefits and costs of operating an MET at a children's hospital. Relying on various derived … of critical deteriorations each year. A prior AHRQ WebM&M perspective discusses early lessons of medical emergency …