Lessons Learned: The Alarm Challenge

We mined the CHPSO database to determine the most commonly reported alarm related incidents. These reported issues align with those identified by The Joint Commission.

Alarm-Related Causal Factors in the CHPSO Database
Equipment related
  • 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 off or muted for reasons of comfort
Environmental design
  • Department or room layout contributed to lack of response to alarms (e.g., difficulty hearing the alarm)

Start with the basics

We have received feedback from many organizations that they feel overwhelmed with the challenge of clinical alarm safety. Here are some steps to get you started in meeting the elements of performance outlined by The Joint Commission’s National Patient Safety Goal on clinical alarm management.

#1: Get the right people on board.

  • Having the right people involved will provide you with valuable insight and will improve acceptance and engagement from all of your staff members
  • Consider including an administrative sponsor who has the authority to approve capital improvements
  • Also include key medical staff, nurse managers, front line clinicians (nurses, respiratory therapists), monitor technicians, clinical informatics, biomedical engineering and a patient safety leader

#2: Gather data to define and understand the extent of alarm safety issues in order to prioritize your improvement efforts.

  • Review your incident data
  • Review alarm types and volume data either through equipment or by direct observation
  • Observe alarm coverage processes; ask clinicians and other staff about their concerns

#3: Simple solutions (preemptive strategies) can be effective.

  • Reduce the noise from non-actionable alarms
    • Change ECG pads, wires, pulse oximeter probes and batteries on a routine basis rather than waiting for them to fail
    • Change default alarm parameters to reflect the needs of the individual patient
    • Sometimes the majority of alarms can be generated from just a couple of patients, so re-evaluate the monitoring needs of those patients

Some organizations have explored the use and effectiveness of middleware and video monitoring to create a quieter environment while still maintaining appropriate monitoring of patients. We will publish more information on these topics as well as other ideas and solutions in future publications of Patient Safety News.

National Coalition for Alarm Management Safety

The Healthcare Technology Safety Institute (HTSI) was developed by the Association for the Advancement of Medical Instrumentation, better known as AAMI, to bring the right people together from across the health care community to address complicated challenges facing the health care technology field. One of their first initiatives is clinical alarm safety. HTSI interacts with hospitals that are making significant progress addressing the TJC National Patient Safety Goal on alarm management. They discovered that although many hospitals are making significant progress, there are as many or more who are struggling for solutions in isolation. They developed the National Coalition for Alarm Management Safety to bring together stakeholders to share what they have learned, build synergies and create common ground where all can agree on certain default parameters that should be set, and on other solution strategies to improve alarm management. The coalition consists of 25 of the nation’s hospitals that are well-along in defining the issues and developing improvement strategies, the FDA, TJC and other professional organizations, such as CHPSO.

There are various alarm management resources available from HTSI, including a webinar series. These presentations and other resources are developed by industry leaders and we recommend that you use them as needed as you develop your plans to address clinical alarm safety.