Root-Cause Analysis and Safety Improvement Plan

Understanding What Happened

What happened?

The nurse working in the cardiac unit has worked there for many years and is accustomed to hearing multiple alarms generated by the bedside monitoring of the patients. The monitoring systems averaged two hundred and ninety-four alarm notifications per patient over multiple 12-hour shifts. Most alarms are either clinically invalid or false alarms. On the night in question, at approximately 9:15 p.m., an alarm sounded for sustained ventricular tachycardia (V-Tach > 100) from the patient's bedside monitor after a heart assessment had been performed on the patient approximately 30 minutes prior to the alarm sounding. The charge nurse, and two of the patient's nurses failed to assess the patient and clear the alarm until after the heart was assessed (i.e. the vitals). Approximately 14 minutes after the alarm, the patient's systolic blood pressure dropped to 81mmHg, and the patient became unconscious until a nursing assistant entered the room and activated the Rapid Response Team upon assessing an emergency situation. As a consequence of this conflict of care, the patient experienced an episode of hypoxia requiring mechanical ventilation for a temporary period of time, remained in ICU for an additional 9 days and experienced permanent mild cognitive impairment as a direct result of prolonged cerebral hypoperfusion. The spouse of this patient submitted a complaint in writing to the committee regarding the patient's avoidable harm due to the desensitization to alarms and the lack of a structured protocol to respond to alarms. The resulting investigation verified that the patient had a critical alarm that had been on the central monitor and on all three bedside monitors for at least 14 minutes and had to have been clinically assessed by nursing staff prior to the alarm being cleared.

Why did it happen?

Human Factors

Due to a long-term exposure to continuous non-actionable alert notifications, nursing staff across both day and evening shifts developed a habitual pattern of dismissing monitor alarm signals. The nurse primarily responsible for Patient B's bedside care acknowledged that she had turned off the alarms on Patient B's telemetry for over 30 of her current shift of duty and that the critical alert notification for atrial fibrillation (ventricular tachycardia) sounded identical in tone versus previous false alerts (Yang et al., 2024). The charge nurse who supervised six patients who were being monitored simultaneously during Patient B's incident did not perform central telemetry monitoring; therefore, there was no centralized oversight of alarms that had gone off during their busiest time during peak evening hours. Cognitive load theory also provides insights into this incident. As hospital staff are exposed to higher than normal levels of stimuli (to include false alarms) that do not represent a clinical need for their response, they will continue to divert their attentional resources away from providing oversight of alarm signals, and there will be a deterioration in their ability to recognize true emergency signals as the amount of time they are exposed to meaningless stimuli increases.

System Factors

The cardiac ICU at Northridge Memorial did not have specific Protocols for Alarm Management specific to each Unit, nor did it have calibration settings that were specifically individualized to each patient based on his or her Physiological Baseline. All monitoring equipment was set up at the Manufacturer Default Settings, which were neither reviewed nor adjusted upon Admission or Daily Rounds; Studies show that this results in substantially higher rates of non-actionable alarms than Individualized Threshold Programming (Güner & Üçüncüoğlu, 2026). The Monitoring Infrastructure of the Hospital did not include Intelligent Filtering Algorithms to distinguish between Artifact and True Arrhythmias, nor did the Monitoring Infrastructure have Tiered Escalation Technology to automatically notify Secondary Responders if the Primary Nurse failed to Respond to an Alarm within a Defined Response Timeframe. There was no formal Alarm Management Committee or Interdisciplinary Oversight Committee in place to regularly review Alarm Event Data, identify High-Burden Units, or implement Corrective Threshold Adjustments.

Organizational Culture

The cardiac ICU's institutional norms reinforced the idea that silencing alarms was a routine nursing practice and that it was an efficient way for nurses to provide care–not a nursing practice that could jeopardize the safety of patients. In post-incident nurse surveys, nurses felt tremendous informal pressure to silence alarms quickly (to limit disturbances to other patients) and to keep the unit noise level within an acceptable range; the thoroughness of alarm response was secondary to the efficiency of workflow (Fouad et al., 2025). The senior nursing leadership had received multiple prior reports indicating that alarm fatigue was becoming a significant safety issue, but had deferred action because of budgetary constraints and competing quality improvement objectives. The lack of evidence that senior nursing leadership was committed to reforming alarm management practices sent an implicit message to the organization that alarm burden was an anticipated condition associated with nurses' occupation, not a systemic hazard that could be corrected.

Society/Culture

The cultural environment of healthcare workers all over the world, impacted by professional norms, has created alarm exhaustion in nurses by discouraging reporting of alarm-related near-misses or raising concerns about monitoring practices with the supervising staff. Nurses trained in high-alarm-volume environments have accepted the practice of rapid silencing alarms as evidence of efficient clinical practice, not as a potential safety risk, and institutional on-boarding procedures have not provided alarm prioritization or response alternative/expanded frameworks (Arkilic et al., 2024). Additionally, the hierarchical dynamics of the ICU made it difficult for junior nursing staff to question alarm response practices or advocate for protocol revisions when they perceived their own competency to be implicitly jeopardized. Additionally, due to the widespread nature of alarm fatigue at many hospitals across the USA, there is a reduced urgency to address alarm fatigue in any given hospital.

Was there a deviation from protocols or standards?

The hospital monitoring policy outlined that nurses must perform a direct check of all patients within 90 seconds of any sustained arrhythmia alarm being triggered. However, documentation shows no response to the Ventricular Tachycardia (VT) alarm activated on Patient B's monitor until 14 minutes after the alarm had first sounded. The Joint Commission’s National Patient Safety Goal (NPSG) 06.01.01 requires health care organizations to develop and implement a written policy detailing how to manage their clinical alarm systems, which includes protocols for responding to alarms, customizing the threshold parameters for alarms, and regulating the escalation process in the event there is no response by the nurse within the specified timeframe. The hospital did not have these operational policies/protocols in place on this unit (Nyarko et al., 2022). The hospital’s equipment management policy stated that threshold parameters for the monitor should be assessed and configured to the individual patient's needs within 24 hours of him/her being admitted; however, upon audit of Patient B’s record, he was placed on factory-default monitor settings for the entire 3 days he was in the ICU without documentation of him being assessed and configured to the monitor. The hospital's policy also required that all critical alarm events be documented in the electronic medical record (EMR) with the nurse’s assessment and rationale for changing the alarm; however, a review of the EMR for the past 14 alarm events on Patient B confirms that the nurse did not meet this requirement. In addition, there were 43 instances where bedside nurses silenced the alarm between 1900-2300, but the alarm escalation protocol requiring charge nurses to conduct an independent assessment of patients after bedside nurses have silenced a predetermined number of alarms within a specified time frame was not triggered or followed for Patient B’s record (Xu et al., 2025).

Who was involved?:

Staff

During Patient B's evening shift, the nurse assigned to care for him was responsible for responding to alarms and checking on his needs while also caring for five other patients with alarms and family communication, administering medications, and assessing post-procedural wounds. During the incident period, the charge nurse had oversight of the unit and some responsibility for monitoring the central station; there was no individual telemetry observer assigned for the shift (Dee et al., 2022). Two other bedside nurses working with patients adjacent to Patient B's bed were aware of the repeated alarm patterns from Patient B's unit. They had both cleared audible alarms without assessing Patient B. This behavior of unintentional dismissal of an alarm occurred regularly throughout the unit as a result of the collective decision by the nursing staff. The nursing assistant responsible for identifying Patient B’s deterioration and activating the Rapid Response Team was not credentialed to review telemetry data or answer alarm communications; however, acted appropriately when the need for assistance was visually obvious.

Supervisors and Managers

Although the ICU nursing manager had access to unit-level alarm event reports generated on a monthly basis by the biomedical engineering department, she had failed to take any action with the data indicating that the cardiac intensive care unit (ICU) has an average of more than 250 alarm events per patient per day (a volume well above published benchmarks in peer-reviewed research indicating that this volume correlates with both alarm fatigue and adverse events) (Alsuyayfi & Alanazi, 2022). The nursing director has been informed of a previous patient safety committee's recommendation to establish an interdisciplinary alarm management task force, yet there have been no staff time allocations or budgetary resources provided for the task force to be established prior to this incident. The patient safety officer had documented three near misses that occurred on the same unit that referenced delayed response to alarms over an eight-month period, but he had labeled each of those issues as an individual personnel performance problem rather than identifying a systemic problem that requires an organization-wide intervention.

Was there a breakdown in communication?

Interdisciplinary Communication

During the afternoon telemonitoring of Patient B, the cardiac monitor tech had indicated in the internal monitoring log that there were unusual alarm densities/variances within the telemetry system. However, this issue was never communicated to the bedside nurse staff or included in the clinical handoff during shift change (Chromik et al., 2022). The cardiologist who reviewed Patient B's post-procedural status during the early afternoon also recorded added arrhythmia risk factors in the physician’s progress note area of the electronic medical record. However, there was no systematic means for notifying nursing staff of the newly updated monitoring parameters requiring increased monitoring due to the implementation of a new drug initiated by pharmacy in the early afternoon, which also included a documented proarrhythmia potential, but was only communicated via the medication administration record and did not generate a nursing alert or initiate a change to alarm threshold recommendations.

Patient-Provider Communication

During afternoon care, Patient B expressed to the nursing assistant that his monitor alarm was going off frequently and that the sound was preventing him from being able to rest. He asked if the alarms indicated something wrong with his condition. This concern was not reported by the nursing assistant to the RN nor recorded in any of Patient B's medical records as it was a patient-reported finding that could have warranted earlier clinical review (Piri et al., 2022). During admission, the admitting RN did not provide sufficient education to Patient B and his family regarding what the monitoring alarms meant; when they should activate their own call light if the alarms are sounding; or what the expected patient and family response is to alarms that sound and remain unanswered. Education regarding alarm significance would have provided Patient B's family with an added level of safety redundancy that may have prompted his family to activate nursing staff earlier in the critical arrhythmia phase.

What were the contributing factors?

Physical Environment

The cardiac ICU was an open bay unit with 12 monitored patient stations; all alarm sounds were heard throughout the entire area at the same time, generating continuous background noise levels described by staff interviews to be psychologically draining and causing cognitive difficulties (Salameh et al., 2024). There was no acoustic zoning, sound-damping, or localized notification technology for alarms from the units. The central monitoring location was located at one end of the unit while nurses were providing care to patients in bays that were much further away. This made it very difficult for the nurse to check the details of an alarm event at the central monitor and made it less practical for the nurse to verify multiple eruptions of alarm during an emergency using central monitoring. The emergency call system and overhead paging alone averaged fourteen (14) different types of interruptions per hour that prevent nursing staff from being able to pay close attention to monitoring their alarm stream.

Staffing Levels

During the evening hours on the cardiac intensive care unit (ICU), the nurse-to-patient ratio of 1:6 was greater than the recommended 1:2 or 1:3 standard for monitored intensive care. This resulted in every nurse having to coordinate multiple responsibilities (e.g., alarms, medication, documentation, and family communication) for twice the number of patients, which is considered unsafe for high-acuity cardiac monitoring (Carelli, et al., 2022). Due to cost-cutting measures instituted six months prior to the event, no telemetry monitoring technicians were assigned to the evening shift, eliminating a secondary layer of surveillance that had previously provided central monitoring oversight without increasing the nursing workload at the bedside. Additionally, budgetary constraints decreased the overlap period from thirty minutes to eight minutes between day and evening shifts, thereby compressing the amount of time available for an adequate clinical handoff and review of the monitoring status of high-acuity patients.

Training and Competency

The review of training records indicates there was no unit-specific alarm management competency development curriculum in place for nursing staff in the cardiac ICU, and training related to alarm response included only a 15-minute module in the general orientation program for the hospital that taught nurses how to operate the equipment but did not teach alarm prioritization strategies (such as recognition of fatigue and escalation protocols) (Movahedi et al., 2023). Additionally, nursing staff received no training on customizing the alarm thresholds or using clinical criteria to determine appropriate ranges of escalation for individual patients with complex histories of cardiac disease. Lastly, the competency assessment for nurses working in the cardiac ICU to evaluate competency regarding alarm management does not include direct observation of how each nurse responds to alarms or how effectively they use established frameworks to prioritize concurrent alarm events; therefore, no deficiencies associated with alarm management practices have been identified via existing methods of performance evaluation.

Did organizational policies or procedures play a role?

Policy Compliance

The clinical alarm management policy established by the hospital (and approved to meet the Joint Commission standards) has designated procedures regarding individualizing alarm thresholds, defining response times, establishing escalation protocols, and requiring documentation of procedures; however, nurses within the cardiac ICU reported that these processes were not being implemented consistently (Albanowski et al., 2023). Following an incident within the cardiac ICU, nursing staff who were interviewed reported that the majority had never been made aware of the response time requirement, nor had they ever had to review and signify review of the alarm management policy as part of their annual competency review. Furthermore, the requirement for alarm threshold parameters being documented as reviewed within 24 hours of admission to a patient was not configured as a required data field within the electronic health record; therefore, non-compliance was not visible to supervisors for the purpose of monitoring compliance with the policy.

Policy Clarity

The hospital’s institutional alarm management policy consists of thirty-two pages that comprise a number of different areas of policies in the hospital's policy library. Additionally, each unit would have specific requirements listed in the general alarm section of the policy, which would be very difficult for someone without thorough familiarity with the document structure to find (Lewandowska et al.; 2023). An important note, however, is that the policy fails to present different types of alarm responses for those patients who have documented arrhythmia risk factors, has no limit to the number of times a patient can silence their monitor alarm in a single shift before the Charge Nurse/Manager is notified and does not specify the level of accountability for the Central Monitoring Specialist during busy nursing periods. There were no concise, unit specific alarm management job aids available to the nurse, no reference cards or electronic health record (EHR) decision support options available for the nurse, and therefore the nurse must rely on their memory in a highly distractible clinical environment to interpret and implement policy.

Was there a failure in monitoring or surveillance?

Post-Discharge Follow-up

A quality monitoring program in the hospital was not currently maintaining an organized way of tracking how many times alarms are sounded, how often they are silenced, and whether or not they were silenced in compliance with hospital standards on a unit-by-unit basis; therefore, the cardiac ICU’s significant number of alarms sounded daily was not recognized as an indicator of quality prior to the incident with Patient B (Huo et al., 2022). The data from alarms generated automatically through monitoring devices is collected and maintained by the biomedical engineering department, but the department does not routinely review this data to determine the clinical safety implications or share the data with the nursing administration, hospital patient safety officers, or hospital quality improvement coordinators in such a way that would create enthusiasm for corrective actions. In relation to the incident reporting system, there is no organized method for recording alarm fatigue-related near-miss events, so alarm fatigue-related safety concerns are generally recorded as “communication” or “monitoring,” which limits the ability to conduct focused evaluations and develop corrective action plans.

Quality Monitoring

The cardiac ICU did not establish baseline metrics for alarm management performance, which hinders both identifying alarm response compliance that is trending downward and comparing the unit's performance to that of other units nationally, for example to American Association of Critical-Care Nurses (Sendelbach & Funk, 2023). The quality improvement department did not monitor alarm management as a patient safety indicator, despite the fact that The Joint Commission has defined alarm safety as a National Patient Safety Goal since 2014. As such, there appears to be considerable disconnect between regulatory back-and-operational performance measurement at this institution. Staff satisfaction surveys consistently indicated that alarm volume and alarm fatigue are major sources of occupational stress over three consecutive annual administrations; however, there has not been any effort to connect this data to an analysis of patient safety risks or use this data to initiate alarm management quality improvements (Nyarko et al., 2023).

What can be learned to prevent recurrence?

Lessons Learned

This adverse event illustrates that the systemic danger of alarm fatigue, in high-acuity monitoring environments, is an institutional hazard, not a failing on the part of individual performers, and that developing sustainable safety improvements requires an acknowledgment of the technological, environmental, staffing and cultural conditions that facilitate and allow alarm desensitization to develop and flourish (Li et al., 2024). It also demonstrates the necessity of operationalizing the Joint Commission's alarm safety guidelines through the establishment of unit-specific protocols with clear accountability, measurable compliance standards and regular supervisory reviews, rather than merely documenting for the purpose of demonstrating compliance with regulations. The case also underscores that patient and family participation in alarm safety, when combined with education to nurses and patients regarding the significance of monitoring and appropriate responses to alarms, provides an underutilized redundancy layer that may contribute significantly to risk reduction.

Quality Improvement

The implementation of a comprehensive package for alarm management will address vulnerabilities in alarm management based on lessons learned from this event. Creating an easily accessible alarm management committee comprised of nursing, medical, biomedical, and quality improvement team members will create an ongoing governance structure that is able to review alarm event data regularly and continuously address alarm burden patterns and ensure adherence to established protocols. This integration of alarm management performance metrics into the current quality monitoring dashboard as well as linking those metrics to nursing leadership performance expectations will assist in creating accountability for alarm safety across both the unit and institutional organizations.

How can patient safety be enhanced?

Risk Mitigation

Making individualized threshold alarm reviews mandatory when documenting and setting up the admitting electronic health record would help reduce the number of non-actionable alarms (Sinno et al. 2022) with the use of patient-specific physiologic profiles to set monitoring parameters, rather than using established generic or default values. Implementing an escalatory notification system that automatically alerts the charge nurse pagers or provides a unit-wide visual alert after an established response time period for critical alarms would eliminate the possibility of having a single point-of-failure that prevented Patient B's irregular heartbeat from being addressed by the nurse for 14 minutes. Implementing a dedicated telemetry role on each shift, staffed by a nurse or technician dedicated solely to monitoring central telemetry, could provide independence from the individual nurse workload when monitoring patients through telemetry.

Education and Training

Creating a thorough alarm management training program that is tailored for cardiac ICUs will provide a solid reading and understanding of what constitutes a proper monitoring procedure (Nyarko et al., 2023). This can be done by providing sufficient classroom training related to customizing alarm thresholds, conducting simulation exercises designed to practice the prioritization of alarms, and using standardized assessments to evaluate nurses' responses to alarms. Annual retraining through direct observation of nurse responses to alarms in combination with using historical alarm data from the unit will help ensure that our standards are enforced and ensure that any nurses in need of additional training can be identified before an untoward event occurs. Providing information about alarm systems to the patient and family members who are admitted to monitored units will provide a patient safety mechanism that is helpful, yet presently not used frequently. The information to be provided includes information on why alarms exist; instructions for independently activating the nurse call system; instructions for appropriately responding to alarms that are delayed in response; and the significance of alarms.

Reporting and Feedback

By means of an incident reporting system to collect data on alarm response failures before they cause any harm to the patient, it is possible to create a dedicated alarm fatigue near miss reporting category. This could allow for a proactive approach to improve safety (Ruppel et al., 2023). To continue to have an ongoing organizational focus on alarm safety, it would be beneficial for all nursing staff, charge nurses, and unit managers to receive a monthly display of unit level alarm performance dashboards that provide summary information pertaining only to the volume of alarms generated, number of times an alarm has been silenced or responded to in compliance with the author's recommendation, and the threshold individualized rate of compliance for each alarm. A psychologically safe reporting environment would encourage nurses to report concerns about the alarm systems, flag patients who are at a high burden of alarm noise, and request support with managing these types of alarms without fear of blame attribution provide the foundation for the development of a culture that will support continuous improvement towards the furtherance of alarm safety.