The Alarm Nobody Answered

Cardiac monitors and telemetry systems generate a constant stream of alarms, the vast majority of which need no action. When a genuine, life-threatening alarm sounds — or when alarms have been turned down, silenced, or switched off to reduce the noise — it can go unheard. Patients have died while their monitors alarmed unanswered.

The Joint Commission's Sentinel Event Alert #50 (2013) documented 98 alarm-related events, most in hospitals, and drove national alarm-management requirements. An estimated 85–99% of alarm signals require no clinical intervention, which is what breeds the desensitization. (Joint Commission Sentinel Event Alert #50, 2013.)

1. A patient on continuous cardiac monitoring generates frequent alarms, most needing no action.
2. Staff, desensitized by the volume, turn alarms down, silence them, or tune them out.
3. A genuine, life-threatening alarm sounds amid the noise.
4. The alarm is not audible where staff are working, or is not recognized as real.
5. A treatable event progresses while the monitor alarms unanswered.

98 alarm-related sentinel events reported to the Joint Commission, January 2009–June 2012 — believed to be a fraction of the true total. (Joint Commission, 2013)

A treatable event progresses unheard. Shown through the monitor, the red alarm bar, the silenced-alarm icon, and the empty nurses' station — never the patient.