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In January 2014, TJC introduced the National Patient Safety Goal on Alarm Management (NPSG.06.01.01) for hospitals and critical access hospitals. Since psychiatric hospitals are surveyed under the Hospital standards, this National Patient Safety Goal is applicable in those settings. Thus, many psychiatric hospitals have been grappling with how best to comply with this new requirement. So, let’s take a look at just what TJC requires and how best to apply that in the psychiatric hospital setting.

The focus of this National Patient Safety Goal is on clinical alarms. TJC defines a clinical alarm as “A component of some medical devices that is designed to notify caregivers of an important change in a patient’s physiologic status. A clinical alarm typically provides audible and/or visible notification of the changed patient status.”

The impetus for this National Patient Safety Goal comes from the acute care hospital setting where it has been shown that a myriad of alarms can result in “alarm fatigue” and staff failing to respond to alarms with resulting fatal consequences for patients.

Psychiatric hospitals typically do not have the abundance and variety of clinical alarms that acute care hospitals have. However, there are some types of alarms that are used in psychiatric hospitals that do fit into this category such as bed and chair alarms for geriatric patients and doorway movement alarms sometimes used on adolescent units.

In addition, it’s important to approach this National Patient Safety Goal from the perspective of complying with the spirit of the requirement and not just the “letter of the law.” For example, while the alarm on the door of an inpatient psychiatric unit may not meet the strict definition of a clinical alarm, it’s critical to know that this alarm is operating properly, has been correctly set, and staff know how to respond to it. (As a case in point, we were part of a root cause analysis two years ago in which a patient escaped from an inpatient unit and died in a traffic accident after a staff member had disabled the alarm because it was malfunctioning.)

So, we have been advising our clients to take the following steps related to this National Patient Safety Goal:

  • Develop an inventory of the alarms in your setting that are designed to alert you to a patient’s status or patient activity that should prompt a staff response
  • Identify in writing the inspection and maintenance procedures for these alarms.
  • Identify in writing the processes in place for monitoring the operation of these alarms.
  • Define staff training requirements related to these alarms and how ongoing competency will be assessed.

Also, be aware that this National Patient Safety Goal requires that effective July 1, 2014 “Leaders establish alarm system safety as a hospital priority.” The best way to do that is to educate your leadership team and medical staff on the background and requirements of this National Patient Safety Goal. Review with them your alarm inventory, inspection/maintenance procedures, monitoring processes and staff training (as outlined above) and get their input on how to make this a top safety priority within your hospital. Document these discussions, plans and actions in your minutes so that you can readily demonstrate to surveyors that you have indeed established alarm safety as a hospital priority.

For additional information on alarm safety, check out the following resources:

ECRI Institute Alarm Safety Resource Site

TJC Sentinel Event Alert: Medical Device Alarm Safety in Hospitals