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policy 0254 : Clinical Alarm Management

The Medical Center is committed to creating and maintaining a culture of clinical alarm (“Patient alarm” or “alarm”) safety that maximizes the effectiveness of clinical systems for patient care. All alarm-enabled medical devices shall be reviewed and approved by Clinical Engineering prior to their implementation on clinical units. Any medical device that is continuously monitoring the patient and creates an alarm shall be set appropriately to predetermined default settings, customized to the patient’s condition or adjusted according to a Licensed Independent Practitioner (LIP)’s order. All health care providers who are involved with patient care are responsible for addressing clinical alarms. Appropriate actions include correcting the condition associated with the alarms and/or communicating with the appropriate direct care provider/shift manager for further investigation and/or resolution of any alarms.

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view  |  PDF document icon 0254_Clinical Alarm Management.pdf — PDF document, 540 KB (553379 bytes)


  1. effective date:

    April 1, 2021