ADMINISTRATIVE POLICY AND PROCEDURE (APP)

DEPARTMENT: BIOMEDICAL
TITLE/DESCRIPTION
POLICY NUMBERCLINICAL ALARM SYSTEM APP-FMS- 002-V5
EFFECTIVE DATE REVISION DUE
04-04-1440HReplaces 04-02-1443H APP-FMS -002-V4 Page 1 of 3
Numberno. of pages
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR HOSPITAL WIDE

PURPOSE
To establish and identify guidelines for monitoring clinical alarm systems and ensure that patients with
clinical alarms are managed safely.
DEFINITION
Clinical Alarm System – is the process of testing alarm systems on clinical equipment during periodic
maintenance inspections and during technician rounds. User verification of proper alarm settings and functions
equipment set-up.
RESPONSIBILITIES
It is the responsibility of the Quality Management Department, Patient Safety Committee, Nursing Department
and Biomedical Engineering Department to implement and monitor this policy.
POLICY
1. Maintenance and Testing of Alarm Systems:
It is the policy of Rafha Central Hospital that the Biomedical Engineering will test alarm systems on
clinical equipment during periodic maintenance inspections and during technician rounds. Equipment
with non-functional alarm settings, whether visual or audible, will be sent to Biomedical Engineering for
repair. As recommended by all equipment manufacturers, user verification of proper alarm settings and
functions will be part of the equipment set-up.
1.1 New equipment shall be checked by Biomedical Engineering before use.
2. Appropriate Settings and Monitoring:
As a policy of Rafha Central Hospital, alarm settings shall be activated and appropriately monitored
according to area / unit's specific criteria or according to the patient’s medical condition / activity level.
Pulse Oximeters on General Care Units:
2.1 Cardiopulmonary/ Respiratory staff shall routinely check pulse oximetry alarms to ensure
alarms are set and functioning appropriately on the general care units.
For ICU:
2.2 Staff shall check cardiac monitoring devices every shift to ensure alarms are set and

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 functioning appropriately.
2.3 Cardiopulmonary and nursing staff shall routinely check ventilator alarms and pulse
ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: BIOMEDICAL
TITLE/DESCRIPTION POLICY NUMBER
CLINICAL ALARM SYSTEM APP-FMS -002-V5
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
04-04-1440H 04-02-1443H APP-FMS- 002-V4 Page 2 of 3
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR HOSPITAL WIDE

oximetry alarms, to ensure alarms are set and functioning appropriately.

3. Alarm Audibility:
Alarms should be sufficiently audible with respect to distances and competing noise within the
unit.
3.1 Different devices have unique sounding alarms. Staffs should be attuned to differentiate
between the alarm sounds.
3.2 If applicable, staff shall place the call bell within patient's reach so the patient may contact
staff when an alarm sounds.
4. Patients who are awake and alert on admission shall be educated about the call system in the
room and bathrooms. Patients and families shall be instructed to notify staff when alarms sound.
5. Education shall be documented on the Patient History and Discharge Record.
6 . Rounds:
Nurses shall routinely make rounds on patients and check when alarms sound.
Alarms are noted on the following equipment but are not limited to:
1. Portable Blood Pressure / Temperature Machine
2. Infusion Pumps
3. Ventilator
4. Pulse Oximeters
5. Ventilator Heater
7. Echo Machines
8. Specialized Bed
9. Warming Blanket (Bear Huggers)
10. Anesthesia Machines
14. Transport Monitors
15. D-Fib Packs
16. Call Bell
18. Cardiac monitors
7-Preventive maintenance must be done in time with follow up of biomedical team and documented with

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action plan if any problem
PROCEDURES
N/A
ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: BIOMEDICAL
TITLE/DESCRIPTION POLICY NUMBER
CLINICAL ALARM SYSTEM APP-FMS- 002-V5
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
04-04-1440H 04-02-1443H APP-FMS- 002-V4 Page 3 of 3
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR HOSPITAL WIDE
EQUIPMENTS
1. Reference Materials (Manual)
2. Leaflets/Brochures from Equipment Manufacturers
CROSS REFERENCES
N/A
REFERENCES
Ministry of Health Guidelines,
CBAHI Standards
FORMS
N/A

APPROVALS
Name Position Signature Date

Prepared by Mohammad Khalid Biomedical Engineer 01-02-1440H

Reviewed by Medwad Shevran Biomedical Director 08-02-1440H

Reviewed by: Fahad Khamis Al Nursing Director 15-02-1440H

Shammari
Reviewed by Dr.Emad Kotb Quality Management 22-02-1440H
Director
Reviewed by: Dr. Mohamad Shams Medical Director 28-02-1440H

Approved By Mohamad Mouhedi Al Hospital Director 04-03-1440H

Najdi