Clinical Alarms Goals

Hospital National Patient Safety Goals
Effective January 1, 2015
Goal 6
Reduce the harm associated with clinical alarm systems.
Improve the safety of clinical alarm systems.
Elements of Performance for NPSG.06.01.01
Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly
managed, they can compromise patient safety. This is a multifaceted problem. In some situations, individual alarm
signals are difficult to detect. At the same time, many patient care areas have numerous alarm signals and the
resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals
or even disable them. Other issues associated with effective clinical alarm system management include too many
devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow. These
issues vary greatly among hospitals and even within different units in a single hospital.
There is general agreement that this is an important safety issue. Universal solutions have yet to be identified, but it
is important for a hospital to understand its own situation and to develop a systematic, coordinated approach to
clinical alarm system management. Standardization contributes to safe alarm system management, but it is
recognized that solutions may have to be customized for specific clinical units, groups of patients, or individual
patients. This NPSG focuses on managing clinical alarm systems that have the most direct relationship to patient
safety. As alarm system management solutions are identified, this NPSG will be updated to reflect best practices. *
Footnote *: Additional information on alarm safety can be found on the AAMI website Also, the ECRI Institute has identified alarm hazards as one of the top technology
hazards for 2013; more information on this hazard list can be found at
–Rationale for NPSG.06.01.01–
Leaders establish alarm system safety as a hospital priority.
Identify the most important alarm signals to manage based on the following:
– Input from the medical staff and clinical departments
– Risk to patients if the alarm signal is not attended to or if it malfunctions
– Whether specific alarm signals are needed or unnecessarily contribute to alarm noise
and alarm fatigue
– Potential for patient harm based on internal incident history
– Published best practices and guidelines
(For more information on managing medical equipment risks, refer to Standard
As of January 1, 2016, establish policies and procedures for managing the alarms
identified in EP 2 above 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
(For more information, refer to Standard EC.02.04.03)
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.