Lessons Learned

Are You Ready for the 2014 National Patient Safety Goal on Alarm Management?

December 2013

Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety. This is a multifaceted problem. In some situations, individual alarm signals are difficult to detect. At the same time, many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them. Other issues associated with effective clinical alarm system management include too many devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow. These issues vary greatly among hospitals and even within different units of a single hospital.

The Joint Commission has been following these concerns and in June 2013, designated clinical alarm safety as a National Patient Safety Goal. Many hospitals are currently developing their implementation plan, so we have added a checklist developed by Association for the Advancement of Medical Instrumentation (AAMI) to assist in that planning.

☐ Dates for compliance with The Joint Commission National Patient Safety Goal on Alarm Management:

  • As of July 1, 2014, leaders establish alarm system safety as a hospital priority.
  • During 2014, identify the most important alarm signals to manage.
  • As of January 1, 2016, establish policies and procedures for managing the alarms identified above and educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.

☐ Link to National Patient Safety Goal on Alarm Management:

http://www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf

☐ Take a proactive system approach

  • Assemble a multidisciplinary team.
  • Review recent events and near-misses.
  • Analyze your current system, including culture, infrastructure, practices, and technology.
  • Identify failures and determine causes.
  • Develop realistic strategies to minimize risk.
  • Carefully plan for implementation.
  • Monitor the effectiveness of strategies and modify as needed.
  • Provide feedback to staff.
  • Celebrate your successes!

☐ Deal with challenges and barriers to implement improved alarm management

  • Measurement of alarm status.
  • Technology limitations.
  • Competing priorities.
  • Overwhelming number of devices with alarms.
  • Financial constraints.

☐ Implement easy strategies first – consider:

  • Change electrocardiographic electrodes daily.
  • Prepare skin properly before applying electrodes.
  • Change telemetry batteries daily.
  • Develop plan to customize physiologic alarms.
  • Implement initial and ongoing education.
  • Consider the appropriateness of the use of devices with alarms.

☐ Always focus on goal to make alarm management safer

  • Minimize patient safety vulnerabilities and reduce risk.
  • Continually improve effectiveness and efficiency of alarm management.

References:

The Joint Commission Announces 2014 National Patient Safety Goal. Available at The Joint Commission website: http://www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf

The Joint Commission’s National Patient Safety Goal on Alarm Management: How Do We Get Started? Sept. 25, 2013. AAMI Foundation HTSI webinar. http://www.aami.org/meetings/webinars/HTSI/resources.html

 

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