Clinical alarm safety and management has become a National Patient Safety Goal for 2014. On April 18, 2013, the Joint Commission issued a sentinel event alert which highlighted the widespread problem of alarm fatigue in hospitals. CHPSO has created this catalog of tools and resources to assist organizations in improving clinical alarm management as well as provide information on alarm management webinars presented by industry experts, as they become available.
CHPSO encourages suggestions of additional tools and better practices. If you have a submittal for this page, please contact us at firstname.lastname@example.org.
CHPSO has been actively engaged with the AAMI Foundation (Association for the Advancement of Medical Instrumentation) to assist hospitals in better managing their alarms. Recently, these efforts have borne fruit.
After tragically losing her 18-month old son Gabriel to medical errors that involved silencing in-room alarms, Leilani Schweitzer presents her story at TEDx University of Nevada to discuss the value of transparency in health care. She explains how, in an act of compassion to allow Leilani some quiet time to sleep, the nurse caring for Gabriel turned off his monitor alarms. These alarms were not active to alert staff when Gabriel’s condition worsened. Her story is a reminder and a call to action for necessary changes in health care delivery.
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.
This Resource Library contains articles and tools from experts on how to learn about and address various alarm safety issues. CHPSO encourages sharing these with your team as your organization works toward achieving the National Patient Safety Goal on clinical alarm management.
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.
Medical device alarms provide essential warnings to alert caregivers of changes in a patient’s condition. When alarms work well, the environment of care is enhanced. When alarms don’t work well, they pull caregivers away from other duties and other patients — or worse, train caregivers to ignore the alarm sounds altogether. Alarms that are ignored can and have resulted in patient deaths.
Experts agree that resolving problems with medical device alarms requires an interdisciplinary effort and buy-in from a wide array of players at the highest levels.
The AAMI Foundation’s Healthcare Technology Safety Institute, along with co-conveners The Joint Commission, ECRI Institute, American Association of Critical-Care Nurses, American Hospital Association, VA National Center for Patient Safety, American College of Clinical Engineering, Healthcare Technology Foundation, and the National Patient Safety Foundation, are pleased to offer a new webinar series on alarm systems management. By the end of the webinar series, healthcare delivery organization alarm management teams will be prepared and confident in complying with The Joint Commission’s new National Patient Safety Goal on alarm management. Click here for more information about the series.