SSR Compliance and Facilities Management Articles

TJC Issues 2014 National Patient Safety Goal on Clinical Alarm System Safety

By David Stymiest, PE, CHFM, CHSP, FASHE

In its Joint Commission Online article dated June 26, 2013 (available at http://www.jointcommission.org/assets/1/23/jconline_June_26_13.pdf) The Joint Commission announced a new 2014 National Patient Safety Goal NPSG.06.01.01 on clinical alarm safety for both hospitals and critical access hospitals.  The July 2013 issue of Joint Commission Perspectives discusses the new NPSG in detail.

The NPSG requirements include 4 elements of performance (EPs) all with the Risk [R] icons that were recently established by TJC to identify patient risks due to a system's proximity to patient, probability of harm, severity of harm, and number of patients at risk.  The 4 EPs are invoked in a phased process:

• Starting on January 1, 2014 and completed by July 1, 2014, hospital leaders are required to establish clinical alarm system safety as a hospital priority.  This EP-1 requirement is scoring category A.
• Starting on January 1, 2014 and to be completed no later than the end of 2014, hospitals are required to identify the most important clinical alarm signals to manage based on their own internal situations.  The EP-2 details include five separate issues (including published best practices and guidelines) to be considered during this identification process.  This EP-2 requirement is scoring category A.
• As of January 1, 2016, hospitals will be expected to establish policies and procedures for managing the alarms previously identified.  The EP-3 details include a minimum of eight separate issues to be factored into the required policies and procedures.  This EP-3 requirement is also scoring category A.
• And finally, as of January 1, 2016, hospitals are required to educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible. This EP-4 requirement is scoring category C.

It comes as no surprise that TJC has issued this NPSG.  We wrote about clinical alarm safety in our late 2012 Compliance Newsletter article about the ECRI Institute’s 2013 top 10 health technology hazards.  Clinical alarm hazards were #1 on that list of top hazards.  (The previous article is available at http://ssr-cfm-articles.blogspot.com/2012/12/compliance-news-ecri-institute-lists.html.)  The NPSG’s current wording is not the end of the story - TJC also states within the NPSG’s Rationale that the NPSG will be updated to reflect best practices as further clinical alarm system management solutions are Identified.