Thomas Bauld: How to Get Started on TJC’s Alarm Management Safety Goal

A Sept. 25 webinar provided a wealth of ideas on how hospitals and other healthcare facilities can prepare for The Joint Commission’s 2014 National Patient Safety Goal related to clinical alarm management. The webinar—hosted by AAMI’s Healthcare Technology Safety Institute in coordination with the support of other organizations, including the VA’s National Center for Patient Safety—effectively “sounded the alarm” on what healthcare professionals need to do to get ready. The fact that 2,100 sites called into the webinar that day—a record for any AAMI webinar—speaks volumes about the level of interest in this issue. Here are the key points I took from the webinar:

  1. While there are many patient safety issues competing for resources, this NPSG has increased the justification for leadership to tackle the management of clinical alarms as a top priority.
  2. It is important to have clinical champions on board to convey the importance of and benefits achieved through alarm assessment and clinician training.
  3. One of the first steps is to focus on a single patient care unit and builds on that. Don’t try to address the entire range of alarm improvement actions at once.
  4. There are several operational and practical changes proven to reduce false alarms, including the implementation of rigorous skin prep and daily ECG electrode changes. Simple and immediate changes to alarm system settings also can make a huge difference, for example eliminating one of a pair of duplicate alarms, such as those for tachycardia and high heart rate.
  5. For older monitoring systems and devices, data collection for assessment of current status and the impact of changes may be difficult, if not impossible. These systems may have very limited capability when it comes to adjusting alarm parameters, severity levels, and alarm delays.
  6. Joining caregivers on their rounds and listening to their concerns are crucial steps to truly understanding the current situation as it relates to clinical alarms.
  7. Capital resources are not always available for major replacements of systems. It’s important to understand such limits when considering alarm management capabilities and the likely long-term goal of equipment standardization.
  8. Some of the impetus for the new NPSG came from the observations of TJC surveyors who saw inadequate alarm responses and discovered that alarms had been turned off. During interviews, senior clinical and administrative leaders indicated that they were unaware of the severity of the clinical alarms problem.
  9. Surveyors will look for compliance to the NPSG beginning in July 2014.   TJC took the unusual step of delaying some major actions until January 2016, in order to give facilities adequate time to address the major issues of assessing the existing alarms and revising alarm policies.
  10. Alarm fatigue is aggravated by excessive noise from non-actionable alarms. Noise is one of the most common root causes for sentinel events.

I am looking forward to the next webinar on Oct. 30, 2013, which will focus on how to identify the most important alarm signals to manage. HTSI has assembled a talented and experienced group of webinar presenters that have much to share.

Thomas Bauld, PhD, CCE, is a biomedical engineer with the VA National Center for Patient Safety.

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2 Comments on “Thomas Bauld: How to Get Started on TJC’s Alarm Management Safety Goal”

  1. Larry Fennigkoh Says:

    Also agree on a great summary Tom – thanks for putting this out here!!

    Reply

  2. Paul McGurgan Says:

    Great summation, Tom. I’ll be sharing it on LinkedIn with the Alarm Fatigue Group.
    Looking forward to the rest of the series.

    Reply

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