TJC issues NPSG on clinical alarms
The concern over "alarm fatigue" and other threats to patient safety from clinical alarms has led The Joint Commission (TJC) to issue a new National Patient Safety Goal (NPSG) on the topic. The new NPSG requires accredited hospitals and critical access hospitals to improve their clinical alarm systems.
The alarm NPSG is in an educational phase and is focused on improving awareness of the potential risks associated with clinical alarms. The second phase begins Jan. 1, 2016, and introduces requirements to control the patient safety risks posed by the alarms.
The new NPSG was deemed necessary after providers reported deaths attributed to alarm fatigue, in which clinicians become overwhelmed by the many alarm signals they hear and purposefully ignore them or just tune them out because of sensory overload. Clinicians can be subject to hundreds of alarm signals every day, the TJC reports, and they sometimes turn down the volume or adjust alarm parameters outside of safe limits. The Joint Commission Sentinel Event database reported eight alarm-related deaths from 2009 to 2012. The Food and Drug Administration database reported 566 deaths between January 2005 and June 2010, according to the TJC report.
In October 2011, TJC and other groups collaborated to find ways to immediately improve clinical alarm safety, and the NPSG is one of the results. (The new NPSG can be found online at http://tinyurl.com/alarmnpsg. For Healthcare Risk Management's previous reporting on alarm fatigue, see the June 2013 issue, p. 68.)