Lessons Learned

An Alarming Finding
January 2013

Clinical alarm safety has been highlighted by the Joint Commission in recent months as they have identified this as a National Patient Safety Goal (NPSG). CHPSO is analyzing alarm-related reports that have been submitted by our members and is seeing some patterns.

In our analysis, we have to take into consideration how our data is collected. Our data is primarily collected from staff-completed incident reports. Staff are most often compelled to complete a report when an incident occurs that is unusual or severely affects a patient. Therefore, volume of reports by category is not indicative of rate of incidence.

The reports fell into the following categories:

  • Problem with equipment
    • False alarm
    • Broken or defective alarm
    • Improperly attached alarm
  • Staff interaction
    • Staff distracted by alarm
    • Staff disabled alarm
  • Patient/family interaction
    • Patient/family disabled alarm
    • Patient/family wanted alarm turned muted/turned off or removed for reasons of comfort
  • Environmental design
    • Department or room layout contributed to lack of response to alarms (e.g., difficulty hearing the alarm)

In an effort to support our members in meeting the requirements of the Joint Commission NPSG and in providing the best care possible to their patients, we will continue to analyze and evaluate these reports; not only to bring awareness of the problems but to also introduce recommended solutions. CHPSO encourages its members to contribute alarm-related incidents to our database to help build a rich knowledgebase for improvement.

Commands