In April 2013, The Joint Commission issued a Sentinel Event Alert that provided hospitals with recommendations for assessing their individual circumstances and developing a systematic, coordinated approach regarding medical device alarms.
The recommendations correspond with those of the Association for the Advancement of Medical Instrumentation (AAMI) and ECRI Institute. Most of the information and guidance provided in these alerts is drawn from The Joint Commission’s Sentinel Event Database, a voluntary reporting system for serious adverse events in healthcare.
The recommendations include the following:
- Create a process for safe alarm management and response in high-risk areas;
- Inventory alarm-equipped medical devices used for high-risk areas and conditions, and identify default alarm settings;
- Have guidelines for tailoring alarm settings and limits for individual patients; and
- Inspect, check, and maintain alarm-equipped devices.
The Joint Commission alert also recommended training and education for all clinical care team members on safe alarm management and response in high-risk areas. Organizations should also consider ways to reduce nuisance alarm signals.
“Patient harm and death that is caused by factors related to alarm management has persisted as the top patient safety issue,” says Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission in Oakbrook Terrace, Ill.
In addition to the alert and existing accreditation standards regarding alarm safety, The Joint Commission issued 2014 National Patient Safety Goals to help healthcare organizations address this issue.
Beginning in January 2014, hospitals were required to identify the most important alarms to manage based on their own internal situations. In phase 2, beginning in January 2016, hospitals will be expected to develop and implement specific components of alarm policies and procedures that address such items as clinically appropriate settings, when settings can be changed, and who is allowed to make such changes. Requirements only apply to organizations accredited by The Joint Commission.