What’s New in the Patient Safety World
February 2013
Joint Commission Proposes New 2014 National Patient Safety Goal
The Joint Commission
had no new National Patient Safety Goals (NPSG’s) for 2013 other than some
enhancements to the CAUTI NPSG and a renewed focus on medication reconciliation
(TJC
2012). But they have already proposed a new NPSG for 2014. This one is a
much needed NPSG that deals with the safety of alarm management (TJC
2013). The proposed NPSG is open for public comment until February 26,
2013.
The proposed new
alarm NPSG has several elements. First, leadership must make focus on alarm
safety a priority. Second, each organization must do an annual inventory of all
systems having alarms and identify default alarm settings for each. Then, from
the inventory, they need to identify which alarms are most important to manage.
Lastly, policies and procedures for managing those alarms must be developed and
implemented. These include things regarding managing alarm parameters,
disabling alarms, responding to alarms, and how you monitor alarms. The latter
would include the ways you check those alarms for accuracy, operation,
audibility, etc. Also, deciding which alarms are really needed is required.
And, of course, there must be educational programs on all those policies and
procedures.
Alarm issues are one
of our favorite topics and we’ve mentioned before that we often make amicable
bets with CEO’s when we enter their facilities that we will find within a
specified timeframe some alarms that have been disabled or otherwise
manipulated.
Checking alarms should be a regular component of your Patient Safety Walk Rounds. More importantly, it should be something your staff does daily on every unit that utilizes alarms of any type. Some units even do it on every shift. You should at least include alarm status as part of your structured handoff tool used at changes of shift. We also strongly recommend that any time you set up a new piece of equipment on a patient you use a checklist specific to that piece of equipment that forces you to verify that all alarms are appropriately set and functional and that parameters chosen are appropriate. We also recommend you review some of the useful tips we’ve included in our February 23, 2010 Patient Safety Tip of the Week “Alarm Issues in the News Again” and the several other columns noted below.
We’ve mentioned several times a provocative article (Lynn 2011) on alarms and why they fail to identify deteriorating patients early. The authors discuss the flaws in current threshold-based alarm systems and the need for true “smart” alarms that integrate multiple physiological parameters and respond to patterns of changes in these. Alarm safety is also always a good topic for a FMEA (Failure Mode and Effects Analysis). For FMEA’s an excellent resource is “Fault Tree Analysis of Clinical Alarms” (Hyman 2008). This is a great way of looking at the potential things that can go wrong, both technical and human, in each of multiple facets of any alarm system.
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 PSA’s 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”
References:
The Joint
Commission. Hospital: 2013 National Patient Safety Goals. October 22, 2012
http://www.jointcommission.org/assets/1/6/2013_HAP_NPSG_final_10-23.pdf
The Joint
Commission. Proposed 2014 National Patient Safety Goal on Alarm Management.
January 15, 2013
http://www.jointcommission.org/assets/1/6/Field_Review_NPSG_Alarms_20130109.pdf
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)
http://www.pssjournal.com/content/pdf/1754-9493-5-3.pdf
Hyman WA, Johnson E. Fault Tree Analysis of Clinical Alarms. Journal of Clinical Engineering 2008; 33(2) 85-94
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