Alarm fatigue

Alarm fatigue or alert fatigue describes how busy workers (in the case of health care, clinicians) become desensitized to safety alerts, and as a result ignore or fail to respond appropriately to such warnings.[1] Alarm fatigue occurs in many fields, including construction[2] and mining[3] (where vehicle back-up alarms sound so frequently that they often become senseless background noise), healthcare[4] (where electronic monitors tracking clinical information such as vital signs and blood glucose sound alarms so frequently, and often for such minor reasons, that they lose the urgency and attention-grabbing power which they are intended to have), and the nuclear power field. Like crying wolf, such false alarms rob the critical alarms of the importance they deserve. Alarm management and policy are critical to prevent alarm fatigue.

Healthcare

The constant sounds of alarms and noises from blood pressure machines, ventilators and heart monitors causes a "tuning out" of the sounds due to the brain adjusting to stimulation. This issue is present in hospitals, in home care providers, nursing homes and other medical facilities alike. The US Food and Drug Administration cataloged 566 deaths from ignored alarms in the period 2005 to 2008.[5] The United States-based Joint Commission's sentinel event reports 80 alarm-related deaths and 13 alarm-related serious injuries over the course of a few years. On April 18, 2013, the Joint Commission issued a sentinel event alert that highlighted the widespread problem of alarm fatigue in hospitals. Their recommendations included establishing guidelines to tailor alarm settings, training all members of the clinical team on safe use of alarms, and sharing information about alarm-related incidents.[4] This alert resulted in designation in 2014 of clinical alarm system safety as a National Patient Safety Goal and it remains a goal in 2017.[6] This Goal will force hospitals to establish alarm safety as a priority, identify the most important alarms, and establish policies to manage alarms by January 2016.[7][8] ECRI Institute has listed alarms on its "Top Ten Hazards List"[9] since 2007; in 2014, alarms were listed as the number one hazard.

Unintended outcomes of alarms

The large number of alarms, especially of false alarms, has led to several unintended outcomes. Some consequences are disruption in patient care,[10] desensitization to alarms,[11] anxiety in hospital staff and patients,[11] sleep deprivation and depressed immune systems,[11] misuse of monitor equipment including "work-arounds" such as turning down alarm volumes or adjusting device settings,[12][13] and missed critical events.[14] Some additional outcomes include workload increase,[11] interference with communication,[14] wasted time, patient dissatisfaction,[14] and unnecessary investigations, referrals, or treatments.[14]

Solutions

There are many solutions proposed to reduce alarm fatigue in healthcare settings:[15]

  • Change alarm sounds to be softer and friendlier in order to improve identification of alarms by sound alone. Another recommendation is for clinicians to adjust the parameters and delays to alarms to match the patient's traits and status. However, this directly trades sensitivity for specificity.[11][14]
  • Use centralized alarms. In this approach, alarms do not fire at the bedside, but fire at a central monitoring station where a trained healthcare provider evaluates each alarm and alerts the bedside clinician if they should intervene or evaluate the patient.[4][16]
  • Adjust alarm algorithms. Currently, the alarm systems are very sensitive but not specific. This leads to a large amount of false alarms. The algorithms used can be adjusted to balance between sensitivity and specificity to limit the number of false alarms and still detect true deterioration.[17]

Child abduction

The amber alert system used in countries such as the United States and Canada to notify the public of a child abduction has been theorized as being susceptible to alarm fatigue.[18][19] A 2018 abduction in Thunder Bay resulted in an amber alert being sent to cell phones as far away as Ottawa, some 15 hours' drive from Thunder Bay, followed one hour later by a second alert which notified individuals that the first alert had been resolved.[20] A similar double alert occurred on a single night in February 2019, leading to concerns over alert fatigue.[21]

Public transport

In the New York City Subway, the Metropolitan Transportation Authority installed sirens in 2006 to discourage subway users from using emergency exits to evade fares; the sirens had little effect other than irritating passengers and were removed in 2015.[22]

Alarm fatigue has sometimes contributed to public transport disasters such as the 2009 train collision in Washington, DC, caused by a faulty track circuit which failed to detect the presence of a stopped train. Though the automatic train control system generated alerts notifying train dispatchers to the presence of such faulty circuits, the rate of such alerts was about 8,000 per week. An investigation by the US National Transportation Safety Board concluded that "the extremely high incidence of track-circuit alarms would have thoroughly desensitized [the dispatchers]".[23]

Weather

Some people[who?] think the large number of deaths from Hurricane Ida in New York and New Jersey may have been the result of too many warnings. Since 2012, weather alerts have been sent out to cell phones, but in 2020, federal officials set up a three-tier system so people would get this warning for the most serious situations.[24]

Warning Labels

California Proposition 65 has been criticized for causing "over-warning"[25] due to encouraging "meaningless warnings."[26][27][28] There is no penalty for posting an unnecessary warning sign,[29] and to the extent that warnings are vague or overused, they may not communicate much information to the end user.[25] Many companies now routinely attach Prop 65 warning labels to any product of theirs that they think might possibly contain one of the 900 listed chemicals without testing to see whether the chemical is really present in their product and without reformulating their product, because it is cheaper to do so than to run the risk of being sued by Prop 65 enforcers.[30]

See also

References

  1. ^ "Alert Fatigue". September 7, 2019.
  2. ^ Blackmon, R.B.; A. K. Gramopadhye (1 June 1995). "Improving Construction Safety by Providing Positive Feedback on Backup Alarms". Journal of Construction Engineering and Management. 121 (2): 166–171. doi:10.1061/(asce)0733-9364(1995)121:2(166). ISSN 1943-7862.
  3. ^ Bliss, JP; Gilson, RD; Deaton, JE (November 1995). "Human probability matching behaviour in response to alarms of varying reliability". Ergonomics. 38 (11): 2300–12. doi:10.1080/00140139508925269. PMID 7498189.
  4. ^ a b c "The Joint Commission Sentinel Event Alert" (PDF). Medical device alarm safety in hospitals. The Patient Safety Advisory Group. Retrieved 21 October 2013.
  5. ^ Medical devices that are music to our ears could save lives
  6. ^ PDF
  7. ^ The Joint Commission. "The Joint Commission Announces 2014 National Patient Safety Goal" (PDF). Retrieved 21 October 2013.
  8. ^ Monegain, Bernie. "'Alarm Fatigue' Endangers Patients." Healthcare IT News. HIMSS Media, 9 April 2013. Web. 24 January 2014
  9. ^ "ECRI Institute Releases Top 10 Health Technology Hazards Report for 2014". Archived from the original on 2016-03-05. Retrieved 2015-09-10.
  10. ^ Healthcare Technology Foundation. "2011 National Clinical Alarms Survey" (PDF). Retrieved 21 October 2013.
  11. ^ a b c d e Borowski, M; Görges, M; Fried, R; Such, O; Wrede, C; Imhoff, M (April 2011). "Medical device alarms". Biomedizinische Technik/Biomedical Engineering. 56 (2): 73–83. doi:10.1515/bmt.2011.005. PMID 21366502. S2CID 17511189.
  12. ^ Meade, Karen; Catania, Kimberly; Lopez, Ben; Connell, Ryan (2019-04-01). "Air-in-Line Alarms: Decreasing Alarms Through Antisiphon Valve Implementation". Clinical Journal of Oncology Nursing. 23 (2): 209–211. doi:10.1188/19.CJON.209-211. PMID 30880809. S2CID 81977608.
  13. ^ Joint Commission. (2013). Medical device alarm safety in hospitals. Sentinel Event Alert, 50, 1–3.
  14. ^ a b c d e Graham, KC; Cvach, M (January 2010). "Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms". American Journal of Critical Care. 19 (1): 28–34, quiz 35. doi:10.4037/ajcc2010651. PMID 20045845.
  15. ^ Copeland, CS (5 February 2019). "National Patient Safety Goals: Reducing the Harm Associated with Clinical Alarm Systems". Vitalacy.
  16. ^ Cantillon DJ, Loy M, Burkle A, Pengel S, Brosovich D, Hamilton A, Khot UN, Lindsay BD (2016). "Association Between Off-site Central Monitoring Using Standardized Cardiac Telemetry and Clinical Outcomes Among Non-Critically Ill Patients". JAMA. 316 (5): 519–24. doi:10.1001/jama.2016.10258. PMID 27483066.
  17. ^ Blum, JM; Tremper, KK (February 2010). "Alarms in the intensive care unit: too much of a good thing is dangerous: is it time to add some intelligence to alarms?". Critical Care Medicine. 38 (2): 702–3. doi:10.1097/ccm.0b013e3181bfe97f. PMID 20083933.
  18. ^ Snow, Robert L. (2008). Child Abduction: Prevention, Investigation, and Recovery: Prevention. Greenwood Publishing Group. ISBN 9780313347870.
  19. ^ Wood, Daniel B. (2017-08-07). "Amber alert fatigue? Alerts on cell phones set Californians buzzing".
  20. ^ "Mobile users warn of 'apathy' after alerts ring out for Thunder Bay abduction". CBC News. 2018-05-14.
  21. ^ "More research needed to determine if alert fatigue is true, says prof". CBC News. 2019-02-16.
  22. ^ Matt Flegenheimer, Exit Alarms in the Subways Are Silenced by the M.T.A., New York Times (January 1, 2015).
  23. ^ "July 27, 2010 Railroad Accident Report – Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten Station Washington, D.C. June 22, 2009". NTSB. July 27, 2010. Retrieved April 10, 2012.
  24. ^ Calvan, Bobby Caina (September 5, 2021). "As flood alerts lit up phones, did 'warning fatigue' set in?". WHYY. Retrieved September 5, 2021 – via Associated Press.
  25. ^ a b "California Hotel & Lodging Association Helps Lodging Guests Understand Proposition 65; Court Approval Obtained for Comprehensive Compliance Procedure" (Press release). California Hotel & Lodging Association. July 7, 2004. Archived from the original on August 24, 2005. Retrieved July 22, 2008. "Unfortunately, the 'safe harbor' warning-sign language specified under Proposition 65 is designed to be so all-encompassing that it is vague and typically doesn't provide much useful information," said Jim Abrams, president and CEO of CH&LA. "People see Prop. 65 warning signs nearly every place they go – grocery and hardware stores, restaurants, commercial buildings, car show rooms, hotels and inns, pretty much everywhere...
  26. ^ Written Testimony of Jeffrey B. Margulies. Proposition 65's Effect on Small Businesses. In the United States House of Representatives, Committee on Small Business. October 28, 1999. "Implications for consumers. While the intent of Prop 65 was to 'inform' consumers, the impact of warnings under the Act has been a proliferation of meaningless warnings. Virtually every business has some sort of Prop 65 warning sign posted, and innumerable products are labeled with the warning. From gas stations to hotels, from grocery stores to hardware stores, consumers are deluged with warnings that they are being exposed to unnamed carcinogens and reproductive toxins. They are not told either the degree of exposure or the likelihood that they may actually be impacted by it. Moreover, because the risks to business of not providing a warning, many provide a warning even though they don't actually know whether an exposure is occurring, or even if the exposure is trivial, further diluting the meaning of warnings to consumers."
  27. ^ Indira Nair and Detlof von Winterfeldt. "Equity and Environmental Justice Considerations in Electromagnetic Field (EMF) Policy" (PDF). Archived from the original (PDF) on July 26, 2011. Retrieved July 22, 2008. This is to be contrasted with Prop. 65 warning experience where the public received meaningless warnings filled with disclaimers, information that trivializes risk, and fails to put it into context.
  28. ^ Consumer Defense Group v. Rental Housing Industry Members, 40 Cal Rptr 3d 832 (Cal. Ct. App. 4th Dist. Div. 3 March 24, 2006) ("Given the ease with which it was brought, and the absolute lack of any real public benefit from telling people that things like dried paint may be slowly emitting lead molecules or that parking lots are places where there might be auto exhaust, instead of $540,000, this legal work merited an award closer to a dollar ninety-eight."), archived from the original on April 11, 2019.
  29. ^ "Proposition 65 Safe Drinking Water and Toxic Enforcement Act of 1986". State of California. 1986. Retrieved July 22, 2008.
  30. ^ "Title 27, California Code of Regulations - Article 6 Clear & Reasonable Warnings: Side-by-Side Comparison" (PDF). December 2017. Archived from the original (PDF) on July 24, 2019. Retrieved July 24, 2019. Companies in every sector of the consumer economy now routinely attach warnings for any of the more than 900 chemicals and elements covered by Proposition 65, without testing for them or attempting to reformulate products. They fear citizen-enforcer lawsuits more than they fear freaking out customers. That profusion of warnings has subverted Proposition 65 and left Californians, and increasingly anyone who shops online, overwarned, underinformed and potentially unprotected, a Times investigation has found. And it has funneled hundreds of millions of dollars to a handful of attorneys and their repeat clients.