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March 26, 2014

Redesigning Hospital Alarms for Patient Safety: Alarmed and Potentially Dangerous

Author Affiliations
  • 1The Patient Safety Enhancement Program, Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan
  • 2Department of Internal Medicine, University of Michigan Health System, Ann Arbor
  • 3Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
JAMA. 2014;311(12):1199-1200. doi:10.1001/jama.2014.710

Because hospital alarms alert clinicians to deviations from a defined normal state, these auditory and visual signals are designed to improve patient safety. Contemporary alarms are diverse, ranging from devices that monitor heart rate to those that sound when patients try to leave their beds. Indeed, it is difficult to imagine modern health care without these electronic sentinels of safety.

Despite their benefits, alarms may also increase the possibility of harm. In a sentinel event alert, the Joint Commission called medical alarms a “frequent and persistent” patient safety problem and designated them 2014 National Patient Safety Goal No. 6 following reports of several alarm-associated deaths.1 Since 2010, the nonprofit ECRI Institute has also rated alarm problems among the top 10 health technology hazards, recently calling them “the number one medical hazard of 2014.”2 Notably, because alarm-associated adverse events are voluntarily reported, the true magnitude of this problem might exceed published estimates. Why may this technology have resulted in adverse outcomes?

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