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Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. April 8, 2013;(50):1-3.
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them, a condition known as alarm fatigue. This sentinel event alert describes how ignoring alarms can have fatal outcomes and recounts an intensive care unit death due to providers' lack of response to alarms signaling a patient's clinical decline. The sentinel event database includes 98 alarm-related events (80 of which resulted in death) between 2009 and June 2012. Because the database relies on voluntary reporting, this number likely represents a small proportion of actual events. The report outlines recommendations and potential strategies for improvement, including guideline development, training and education, and establishment of a cross-disciplinary team of clinicians, clinical engineers, information technologists, and risk managers focused on alarm safety. The Joint Commission is also considering developing a related National Patient Safety Goal to address this issue.
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.