AST Guideline - Best Practices in Alarm Management in the Operating Room

5 Guideline IV The surgery department should review the policies and procedures (P&P) regarding safe alarm management on an annual basis. 1. Universal solutions and standardization contribute to safe alarm management, but have yet to be established with the recognition that solutions may have to be customized and a “one- size-fits-all” approach will not work even within the various departments of a HDO due to differences in the environment of patient care, patient needs, and staff readiness. 2 However, the surgery department should develop a systematic, coordinated approach to alarm management that is practiced on a uniform basis by the surgery department staff. 20 2. The surgery department should include members of the surgical team and administration when reviewing the P&Ps, including CSTs, surgeons, anesthesia providers, RNs, risk management, information technology, and healthcare management technicians. A. It is recommended that the surgery department create an alarm safety management committee that is responsible for the review and revision of P&Ps, review of adverse events and providing continuing education. 15 This would eliminate the uncertainty of who is responsible for creating and managing alarm system P&Ps. 2 B. The review and revision process of P&Ps should include administering staff surveys to gather their feedback regarding alarm management including identifying their perceptions and concerns. 2 C. It is recommended to review the P&Ps from other HDOs to consider adopting or adopting with revisions to meet the needs of the surgery department, i.e. don’t reinvent the wheel. 2 3. The surgery department should confirm the elements of performance (EP) from the National Patient Safety Goal on Alarm Management issued by TJC are incorporated in the P&Ps. 20 A. As of July 1, 2014, HDOs should have established alarm system safety as a hospital priority. B. Additionally, during 2014, the HDOs should have identified the most important alarm signals to manage based on the following: 1) Input from the medical staff and clinical departments. 2) Risk to patients if the alarm signal is not attended to or if it malfunctions. 3) Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue. 4) Potential for patient harm based on internal incident history. 5) Published best practices and guidelines. C. As of January 1, 2016, HDOs should have established P&Ps for managing alarms that, at a minimum, address the following: 1) Clinically appropriate settings for alarm signals. 2) When alarm signals can be disabled. 3) When alarm parameters can be changed. 4) Who in the organization has the authority to set alarm parameters. 5) Who in the organization has the authority to change alarm parameters. 6) Who in the organization has the authority to set alarm parameters to “off”. 7) Monitoring and responding to alarm signals. 8) Checking individual alarm signals for accurate settings, proper operation, and detectability.