NURS 492 Week 4 Research: The Science of Nursing Part 2 Example

Too Many Alarms: A Literature Review on Reducing Nonactionable Cardiac Monitor Alarms in Progressive Care

Introduction

On my 28-bed progressive care unit, almost every patient wears a cardiac monitor, and the central station sounds an alarm every few seconds through most of a shift. A one-week review by our unit council found that most alarms required no action: leads off, artifact from movement or heart rates just past a default limit that was never adjusted for the patient. Nurses admit that they sometimes silence alarms without looking, and two near misses last year involved arrhythmia alarms that were not answered quickly. In one, a patient's run of ventricular tachycardia was noticed only when the monitor technician called the unit, nearly a minute after the alarm began. Nobody on shift that night was careless; the alarm had simply sounded like the hundreds of others before it. This review examines the evidence on one practice, the management of cardiac monitor alarms, and asks which interventions reduce nonactionable alarms safely and how gains can be sustained.

Search Strategy

I began with the American Association of Critical-Care Nurses, the organization studied in Part 1, and selected a research article from its American Journal of Critical Care (Güner & Üçüncüoğlu, 2026). I then searched PubMed and CINAHL for peer-reviewed articles published since 2021 using the terms alarm fatigue, nonactionable alarms, physiologic monitoring and telemetry. I included systematic reviews, meta-analyses and quality improvement studies relevant to adult or pediatric inpatient monitoring and excluded opinion pieces. Six articles met the criteria and are synthesized below by theme, alongside the AACN practice alert on alarm management.

How Common and How Severe Is Alarm Fatigue?

The studies agree that alarm fatigue among nurses is moderate on average and widespread. Güner and Üçüncüoğlu (2026) surveyed 60 nurses in two cardiac intensive care units and interviewed others until saturation; nurses reported moderate alarm fatigue that rose with their discomfort with alarms. Shaoru et al. (2023) pooled 14 cross-sectional studies of 2,848 clinical nurses and also found moderate levels, with higher fatigue among nurses who worked nights and those with lower professional rank. Zhu et al. (2026) pooled 28 studies of 6,908 intensive care nurses and reached a similar conclusion, while cautioning that heterogeneity was extremely high. Taken together, these reviews suggest the problem is consistent across countries and settings even though the measurements differ. None of the three studied progressive care units directly, but progressive care patients are monitored as continuously as intensive care patients with fewer nurses per patient, so there is little reason to expect the problem to be smaller there.

The consequences are serious. Zhu et al. (2026) found directional evidence linking higher alarm fatigue to a greater tendency toward medical errors and to burnout. Michels et al. (2025), in a scoping review of 32 publications, proposed a common definition, describing alarm fatigue as sensory overload and gradual desensitization from repeated, frequent or nonactionable alarms, which leads to delayed or inadequate responses. They linked it to delayed responses, communication breakdowns, stress and burnout. The near misses on my unit fit that description exactly. The consequences also reach patients directly: the qualitative participants in Güner and Üçüncüoğlu's study described how alarms disturbed conscious patients, which on my unit means interrupted sleep for people recovering from heart failure and arrhythmias.

What Contributes to Alarm Fatigue?

The studies point to causes at several levels. At the device level, false and nonactionable alarms are the most consistent contributor: Zhu et al. (2026) found that false alarms and low trust in alarms showed adverse signals, while alarm management support and better work environments appeared protective. At the individual level, Shaoru et al. (2023) identified night shift work and lower professional rank, and Michels et al. (2025) noted psychosocial work conditions and individual traits. At the organizational level, the nurses Güner and Üçüncüoğlu (2026) interviewed described alarms as an organizational problem, involving staffing, equipment and policy, not only a personal one. Sowan et al. (2022), summarizing the state of science through a sociotechnical model, argued that alarm safety comes from how devices, clinicians, workflow and policy work together, and that interventions focused on a single dimension tend to fall short.

Which Interventions Reduce Nonactionable Alarms?

The intervention studies converge on a bundle of practices. The AACN practice alert calls for skin preparation and daily electrode changes, alarm settings customized to the patient and monitoring limited to patients with a clinical indication (American Association of Critical-Care Nurses, 2018). Feurer et al. (2025) implemented such a bundle on two 26-bed adult acute care units where a chart review had found an average of 19.44 alarms per patient per hour. Adherence to daily electrode changes reached 80% and documentation of customized parameters reached 86%, but nurse-driven customization of heart rate limits occurred in only 17% of opportunities and lead placement errors occurred 34% of the time. The authors concluded that the bundle could be introduced safely and reduced nonactionable alarms, but their adherence data show how hard individual elements are to sustain. The weakest element, nurses adjusting heart rate limits themselves, is the one that depends most on individual judgment and confidence, which suggests that education and clear authority to customize limits deserve as much attention as supplies and policy.

Akahoshi et al. (2026) provide the largest dataset: 46,302,740 alarms in 65,720 patients across nine pediatric wards from 2016 to 2024. A first phase of monthly data review, daily electrode replacement and discussions of when to discontinue monitoring cut alarms from about 143 to 99 per patient per day. A second phase added patient-specific thresholds and reminders to reconsider settings and reached the lowest rate of 86. Michels et al. (2025) similarly identified training, technical customization, protocol changes and organizational interventions as the main strategies in the literature. The common thread is that no single change was enough. Electrode care removes artifact alarms, individualized limits remove alarms that are accurate but clinically meaningless for a particular patient and discontinuing unnecessary monitoring removes alarms altogether. Each addresses a different source of noise, which is why the studies that combined them achieved the largest reductions.

Why Do Gains Fade?

The most important finding for my unit may be the least encouraging. In Akahoshi et al. (2026), alarm rates rebounded to 124 per patient per day after the first phase ended and to 165, the highest level recorded, after the second. The authors concluded that the interventions worked while active but were unsustainable without a durable framework. Feurer et al. (2025) reported a similar pattern in adherence to individual bundle elements. Sowan et al. (2022) recommended that clinical leaders treat alarm safety as an ongoing system responsibility, with governance, data and accountability, rather than a one-time project. Alarm fatigue is not fixed by a project; it is held back only by a practice that never stops.

Limitations of the Evidence

The evidence has clear limits. The meta-analyses rely on self-reported questionnaires and show very high heterogeneity, and most studies are cross-sectional. The strongest intervention data come from a pediatric setting, where movement and crying generate different alarms than in adults. The adult project was a single-site quality improvement effort without a control group. Patient outcomes were rarely measured at all, so the claim that fewer alarms prevent harm rests mostly on reasoning and near-miss reports, not on trials.

Recommendations for Practice Change

Based on this review, I will recommend four changes to our unit council. First, change electrodes daily after skin preparation, documented in the record, as the AACN alert and both intervention studies support. Second, require every nurse to review and individualize heart rate and arrhythmia limits within an hour of taking report, with a short competency on safe customization, since Feurer et al. (2025) found this was the least adopted element. Third, review each patient's monitoring indication daily with the provider so that monitoring is discontinued when it is no longer needed. Fourth, build sustainability in from the start: a monthly alarm report by patient day, quarterly review by the unit council and new-hire education, because Akahoshi et al. (2026) showed that alarm rates return when attention stops. Success will be measured by alarms per patient per day, the proportion of nonactionable alarms in a monthly sample, adherence to each bundle element and nurses' alarm fatigue scores before and after the change. As a balancing measure, the council should also track any missed arrhythmias or rapid responses linked to monitoring, so that the effort to reduce alarms never trades noise for danger.

Conclusion

The literature agrees that alarm fatigue among nurses is moderate, widespread and dangerous, that it arises from devices, people and organizations together and that a bundle of electrode care, individualized limits and appropriate monitoring reduces nonactionable alarms. It also warns that improvements fade without lasting structures. For a progressive care unit, the evidence supports adopting the AACN's recommended practices as a permanent part of how the unit works, measured and reviewed as routinely as falls or infections.

References

Akahoshi, S., Nagasawa, S., Fukuda, K., Iio, K., Kawata, N., Minegishi, H., Sakatani, M., Kinumaki, A., Tomotsune, M., Morikawa, Y., & Hataya, H. (2026). Sustainability of bundled approaches to alarm fatigue: Lessons from a long-term quality improvement study. Journal of Hospital Medicine, 21(1), 34-41. https://doi.org/10.1002/jhm.70129

American Association of Critical-Care Nurses. (2018). Managing alarms in acute care across the life span: Electrocardiography and pulse oximetry. Critical Care Nurse, 38(2), e16-e20. https://doi.org/10.4037/ccn2018468

Feurer, A. L., Fitzpatrick, S., & Wise, B. (2025). Reducing nuisance telemetry alarms in the adult inpatient setting. Journal of Doctoral Nursing Practice. Advance online publication. https://doi.org/10.1891/JDNP-2024-0061

Güner, Y., & Üçüncüoğlu, M. (2026). Identifying the alarm fatigue status of nurses working in cardiac intensive care units: A mixed-design study. American Journal of Critical Care, 35(1), 32-43. https://doi.org/10.4037/ajcc2026265

Michels, E. A. M., Gilbert, S., Koval, I., & Wekenborg, M. K. (2025). Alarm fatigue in healthcare: A scoping review of definitions, influencing factors, and mitigation strategies. BMC Nursing, 24(1), 664. https://doi.org/10.1186/s12912-025-03369-2

Shaoru, C., Hui, Z., Su, W., Ruxin, J., Huiyi, Z., Hongmei, Z., & Hongyan, Z. (2023). Determinants of medical equipment alarm fatigue in practicing nurses: A systematic review. SAGE Open Nursing, 9, 23779608231207227. https://doi.org/10.1177/23779608231207227

Sowan, A. K., Staggers, N., Reed, C. C., Austin, T., Chen, Q., Xu, S., & Lopez, E. (2022). State of science in alarm system safety: Implications for researchers, vendors, and clinical leaders. Biomedical Instrumentation & Technology, 56(1), 19-28. https://doi.org/10.2345/0899-8205-56.1.19

Zhu, L., Wei, S., An, Y., Hu, W., & Xie, X. (2026). Severity and associated factors of alarm fatigue among intensive care unit nurses: A systematic review and meta-analysis. Nursing in Critical Care, 31(5), e70666. https://doi.org/10.1111/nicc.70666