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
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.