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June 2017

A Complex Phenomenon in Complex Adaptive Health Care Systems—Alarm Fatigue

Author Affiliations
  • 1School of Nursing, University of Texas Health at San Antonio, San Antonio, Texas
  • 2Nursing Care Excellence Center, University Health System, San Antonio, Texas
JAMA Pediatr. 2017;171(6):515-516. doi:10.1001/jamapediatrics.2016.5137

The excessive number of nonactionable and false alarms signals from medical devices produces alarm fatigue.1,2 Alarm fatigue is a cognitive stress adaptation technique that results in unsafe workarounds, such as a delayed response time to alarms, disabled alarms, volumes set to inaudible, parameters limits set to unsafe zones, or alarms paused without a thoughtful consideration of the warning message. Alarm fatigue is a national patient safety concern1-3 and, to our knowledge, the most common factor contributing to alarm-related deaths.2,4 Physiologic monitors are the medical devices associated with the highest number of alarms5 and deaths.4

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