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Effective January 1, 2016

The National Patient Safety Goal on Alarm Management (NPSG.06.01.01) went into effect in January, 2014 for hospitals. 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.”

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 used in psychiatric hospitals that do fit into this category such as bed and chair alarms for geriatric patients and perhaps even doorway movement alarms sometimes used on adolescent units. When this National Patient Safety Goal went into effect in 2014, the requirement was that “leaders establish alarm system safety as a hospital priority.” Essentially, that required clinical leadership to identify the alarms that needed to be managed, their risks, and best practices for managing these alarms. Surveyors have been reviewing compliance with these requirements in 2014 and 2015.


Effective January 1, 2016, the next set of requirements goes into place. These are as follows:

EP 3: As of January 1, 2016, establish policies and procedures for managing the alarms … that, at a minimum, address the following:

  • Clinically appropriate settings for alarm signals
  • When alarm signals can be disabled
  • When alarm parameters can be changed
  • Who in the organization has the authority to set alarm parameters
  • Who in the organization has the authority to change alarm parameters
  • Who in the organization has the authority to set alarm parameters to “off”
  • Monitoring and responding to alarm signals
  • Checking individual alarm signals for accurate settings, proper operation, and detectability


EP 4: As of January 1, 2016, educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.

Undoubtedly, surveyors will be reviewing compliance with these requirements as surveys commence in 2016. So, we recommend that hospital leadership take the following actions:

  • Establish a policy/procedure for each of the clinical alarms in use. (This is usually feasible given the limited number of alarms typically used in a psychiatric hospital.)
  • Make sure that the policy/procedure addresses each of the elements listed above in EP# 3.
  • Establish a schedule for the testing and maintenance of the alarms and required documentation.
  • Determine which department and/or hospital committee will review the data on the testing and maintenance of the alarms.
  • Establish a mechanism for educating staff and LIPs (MDs, NPs, etc.) about their role in the safe operation of these alarms. Document this training in their HR files.

Being proactive about management of clinical alarms is an important aspect of the hospital’s safety program. Putting in place mechanisms to avoid a sentinel event or critical incident is well worth the effort up front. Learn more about how we can help with our Patient Safety Review Services.


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