Alarm management compliance shifts into second gear

Accreditation Insider, March 15, 2016

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For the last two years, healthcare organizations have been working to comply with the first phase of The Joint Commission's alarm management National Patient Safety Goal (NPSG). As of January 1, 2016, they'll have to contend with the second phase as well.

Phase II of NPSG.06.01.01 requires hospitals to build on the work they've done for the past two years and establish policies and procedures for the high-risk alarms identified during the first phase of the standard. According to the standard, hospital policies are expected to address issues such as clinically appropriate settings, when those settings should be changed, and who has the authority to change alarm parameters. Hospitals are also required to educate staff on how to properly operate alarms to reduce alarm fatigue.

Although the first phase of NPSG.06.01.01 was fairly prescriptive, the second phase is a little more vague, says JoAnne Phillips, MSN, RN, CCRN, CCNS, CPPS, manager of quality and patient safety at Penn Home Care & Hospice Services, and a clinical informatics professional development specialist at the University of Pennsylvania Health System in Philadelphia. Although it's difficult to know exactly what surveyors will be looking for, the standard offers some wiggle room to address the unique alarm safety risks in each hospital.

"In talking to different people across the country, what I've found there is [a] lot of variation in the way people are approaching this," she says.

Perhaps the most difficult element of the second phase will be putting policies into practice, says Rikin Shah, senior associate with the ECRI Institute in Plymouth Meeting, Pennsylvania. That transition requires not just the right written policies, but also a culture of safety that will support necessary changes.

"I believe culture is going to be the common denominator as far as how some of these policies are going to be turned into practice," Shah says. "That's one of those things that can't be predicted and can't be calculated. Everything can be done right on paper, but how that translates into human behavior, we just don't know."

While cultural factors will play a huge role in how well health systems improve safety concerns surrounding device alarms, hospitals should be prepared to show Joint Commission surveyors the risk analysis used to identify problematic alarms, the policies and procedures that address those risks, and the widespread education initiatives targeting staff awareness.

This is an excerpt from the March issue of Patient Safety Monitor. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

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