Whats New in the Patient Safety World
August 2013
Joint Commission Formalizes 2014 NPSG on Alarm Management
The Joint Commission
has now approved the new National Patient Safety Goal for 2014 on clinical
alarm safety and management (NPSG 06.01.01). The content is pretty much as
described in our Whats New in the Patient Safety World columns for February 2013 Joint
Commission Proposes New 2014 National Patient Safety Goal and May 2013 Joint
Commission Sentinel Event Alert: Alarm Safety. However, the announcement (Joint
Commission 2013) has a considerable change in the expected timeline,
allowing hospitals much more time for full implementation. The Joint Commission
has done this in view of ongoing studies developing best practices for alarm
management.
The new NPSG
requires as of July 1, 2014 all affected organizations establish alarm system
safety as a priority and in 2014 to identify the most important alarm signals
to manage (based on input from staff, risk to patients, clinical necessity of
alarms vs. unnecessity that might contribute to noise and alarm fatigue,
potential for patient harm based on internal incident history, and published
best practices and guidelines).
However, it then
gives organizations until January 1, 2016 to develop policies and procedures
and staff educational programs to manage the alarms identified in the above
exercise.
The announcement also provides links to two good websites for tracking best practices and advances in alarm management, the AAMI HTSI website and ECRI Institutes Alarm Safety Resource Site.
We certainly hope
that this reprieve does not discourage organizations form moving forward
expediently in improving alarm system management. The Joint Commission
recognizes that many best practices will be developed or refined over the
coming years and presumably is allowing for such changes to impact systems.
A good place to
start is our July 2, 2013 Patient Safety Tip of the Week Issues
in Alarm Management which has some comprehensive recommendations about
alarm safety and management. It has many links to useful resources and to many
of our prior columns on alarm-related issues that include some chilling stories
of adverse outcomes related to improper alarm issues and their root causes.
Prior Patient Safety
Tips of the Week pertaining to alarm-related issues:
- March 5, 2007 Disabled Alarms
- March 26, 2007 Alarms Should Point to the Problem
- April 2, 2007 More Alarm Issues
- June 19, 2007 Unintended Consequences of Technological Solutons
- April 1, 2008 Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
- February 23, 2010 Alarm Issues in the News Again
- March 2, 2010 Alarm Sensitivity: Early Detection vs. Alarm Fatigue
- March 16, 2010 A
Patient Safety Scavenger Hunt
- November 2010 Alarms in the Operating Room
- February 22, 2011 Rethinking
Alarms
- February 2013 Joint
Commission Proposes New 2014 National Patient Safety Goal
- May 2013 Joint
Commission Sentinel Event Alert: Alarm Safety
- July 2, 2013 Issues
in Alarm Management
References:
The Joint Commission. The Joint Commission Announces 2014 National Patient Safety Goal. July 19, 2013
http://www.jointcommission.org/joint_commission_announces_2014_npsg/
AAMI HTSI website (AAMI Healthcare Technology Safety Institute).
http://www.aami.org/htsi/alarms/library.html
ECRI Institute. Alarm Safety Resource Site.
http://www.ecri.org/Forms/Pages/Alarm_Safety_Resource.aspx
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