Two Minutes of Silence That Never Ended

Monitors let staff pause or silence alarms briefly — to reposition a patient, draw blood, or stop a nuisance alarm. If the pause is not un-paused, or the alarm is switched off and forgotten, the monitor watches in silence when it matters.

The Joint Commission's Sentinel Event Alert #50 found that of 98 alarm-related events, 36 involved alarm signals that were inappropriately turned off — the single largest contributing-factor category. (Joint Commission SEA #50, 2013.)

1. A clinician pauses or silences a monitor alarm to perform a task or quiet a nuisance alarm.
2. The task ends but the alarm is not un-paused, or it is switched off and forgotten.
3. An interruption or handoff carries the clinician away before the alarm is restored.
4. A genuine, life-threatening change occurs.
5. The monitor detects it but does not sound where staff can hear.

Of 98 alarm-related events reported to the Joint Commission, 36 involved alarms turned off or inappropriately silenced. (Joint Commission, 2013)

A monitor silenced when it should have spoken. Shown through the paused-alarm icon and the quiet monitor — never the patient.