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Thursday 7:22 CST, December 18, 2014


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June 26, 2013

New NPSG on clinical alarm safety: phased implementation in 2014 and 2016

Joint Commission Requirements

The Joint Commission approved a new National Patient Safety Goal (NPSG) on clinical alarm safety (NPSG.06.01.01) for 2014 for hospitals and critical access hospitals. The new goal will be implemented in two phases: phase one begins January 1, 2014, when hospitals will be required to establish alarm safety as an organizational priority and identify the most important alarms to manage based on their own internal situations; phase two begins January 1, 2016, when hospitals will be expected to develop and implement specific components of policies and procedures, and to educate staff in the organization about alarm system management. 

The Joint Commission will publish the phase one and two requirements at the same time in order to provide complete information about the ultimate requirements of the NPSG. It is important to note, however, that the proposed phase two requirements may be enhanced before they are implemented in 2016. These changes could arise from hospitals’ experience with phase one requirements as well as newly emerging evidence about best practices. The Joint Commission is aware of efforts currently underway that will support the implementation of phase two requirements. For example, the Association for the Advancement of Medical Instrumentation’s (AAMI) Healthcare Technology Safety Institute (HTSI) is engaged in a number of activities that promote safe alarm system management, including:

  • Conducting a survey and study of hospital practices in setting alarm parameters.
  • Posting literature on the HTSI website about best practices on alarm system management; this literature is reviewed by a best practices work group.
  • Offering webinars on safe alarm management.

The proposed NPSG was reviewed by Joint Commission advisory committees, which supported the NPSG because it focuses attention on the safety issue; however, they noted that solutions will be evolving over many years. If any changes to the phase two requirements are made, accredited hospitals will be notified through field review and Perspectives.

Both the AAMI and ECRI Institute websites contain useful information on safely managing alarm systems. In addition, The Joint Commission published a Sentinel Event Alert on clinical alarm management in April. The Alert contains suggestions for assessing and managing risks associated with alarms, and complements the expectations of the new NPSG. Additional Joint Commission resources on the topic include two Take 5 podcasts and the replay of a webinar held in May. The new NPSG will be published in the Comprehensive Accreditation Manual for Hospitals (CAMH) in the fall and in Update 2 to the CAMH in 2013, and the E-dition will be updated in October. (Contact: Maureen Carr,



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