Safety Innovations Series

Safety Innovation SeriesThe Safety Innovations series is a collection of white papers, reports, and guides from the AAMI Foundation that:

  • Illuminate how leading healthcare organizations have solved a particularly tough technology-related safety issue (e.g., clinical alarm systems; infusion systems)
  • Share pathways to implementing technology-based recommendations from outside experts
  • Provide analytical tools for solving technology-related patient safety issues.

From planning to implementation, all papers in this series are aimed to help healthcare organizations find innovative solutions to improve technology-related patient safety.

We encourage you to share Safety Innovations papers with your colleagues.  They are free to download or forward to others.

The AAMI Foundation is very interested in how hospitals have implemented the healthcare technology strategies outlined in the Safety Innovations papers. If you have a success story to share based on recommendations mentioned in any of the papers, please share it with us.  If you have a  technology-related case study to share, please let us know.  Contact us at

The following papers may have a webinar related to the topic.  Please check the Safety Innovation Series Webinars Recordings & Slides.


Title: Alarm System Vocabulary according to industry accepted standards; IEC 60601-1:2006+A1:2012
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Home Healthcare

Title: Innovations in Managing Pediatric Home Medical Equipment
Facility: Pediatric Home Service (PHS)
Description: Since it was founded in 1990, PHS has been working to support extremely ill patients in the home environment.
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Clinical Alarms

Title: Clinical Practice Changes Associated with Alarm Standardization
Facility:  Boston Medical Cemter
Description:  BMC’s alarm journey began in 2008 with the standardization of all cardiac monitoring equipment across the medical center. In 2011 with increasing focus nationally on alarm fatigue and the report of sentinel events from missed alarms, BMC reconvened its multidisciplinary task force to look at opportunities to decrease the volume of audible alarms particularly on its medical surgical units.
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Title: Healthcare Alarm Safety—What We Can Learn From Military Alarm Management Strategies
Facility: Lockheed Martin (LM) Advanced Technology Laboratories
Description: Daniel McFarlane, Sc.D. of LM Advanced Technology Laboratories provides insight on ways to enhance hospital alarm management, reflecting upon innovative alerting systems utilized by the Navy to improve warfighter awareness and capabilities.
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Title: Simple Solutions for Improving Patient Safety In Cardiac Monitoring—Eight Critical Elements to Monitor Alarm Competency
Facility: University of Pittsburgh Medical Center (UPMC); Presbyterian Hospital
Description: UPMC realized that improving the utilization and management of non-life threatening arrhythmia alarm conditions could reduce alarm fatigue and preserve patient safety. UPMC Presbyterian launched pilot projects that would result in: decreasing alarm ring time, improving staff response to cardiac monitor alarm signals, and decreasing alarm noise within hospital units that contain a high volume of monitoring equipment.
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Title: Safeguarding Patients with Surveillance Monitoring
Facility: The Dartmouth-Hitchcock Medical Center
Description: A series of adverse events led clinicians and researchers at Dartmouth-Hitchcock Medical Center to a humbling conclusion: Healthcare professionals were handicapped by their limited ability to detect signs of patient deterioration and to predict which patients were at risk for adverse events in the first place. Dartmouth-Hitchcock responded with stopgap measures to safeguard patients, including double checks of opioid administration, smart patient-controlled analgesia (PCA) pumps, and rapid response teams.
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Clinical Alarms Webinar

Title: Cardiopulmonary Monitors and Clinically Significant Events in Critically Ill Children
Facility: Children's National Medical Center
Description: A team of nurses, biomedical engineers, physicians, and biostatisticians were assembled to assess the conditions associated with the generation of cardiopulmonary monitors (CPMs), including false positive alarms signals in critically ill children, and to define alternative alarm parameters that would improve CPM alarm performance.
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Clinical Alarms Webinar

Title: Plan, Do, Check, Act: Using Action Research to Manage Alarm Systems, Signals, and Responses
Facility: The Beth Israel Deaconess Medical Center
Description: In the aftermath of two sentinel events in inpatient rooms at the Beth Israel Deaconess Medical Center in Boston, MA, the hospital’s leadership, and the physician, nursing, and clinical engineering staff focused comprehensively on alarmed medical devices.
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Clinical Alarms Webinar

Title: Recommendations for Alarm Signal Standardization and More Innovation
Facility: The Christiana Care Health System
Description: Christiana Care developed a system-wide alarm policy and protocols that defined its alarm management strategy for alarmed medical equipment, including flex monitors, standard cardiac monitors, pulse oximeters, and infusion pumps.
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Clinical Alarms Webinar

Title: Using Data to Drive Alarm System Improvement Efforts, The Johns Hopkins Hospital Experience
Facility: The Johns Hopkins Hospital
Description: The key to reducing alarm signal noise is the collection and analysis of quantitative data to evaluate the applications of alarm system management in hospitals.
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Clinical Alarms Webinar

Infusion Systems

Title: Best Practice Recommendations for Infusion Pump-Information Network Integration
Description: Pump integration requires pervasive and reliable wireless coverage—if pumps can’t communicate with the server via a wireless network, no integration can occur.
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Title: Nine Recommendations to Prevent Multiple Line Infusion Medication Errors
Description:  The study, Mitigating the Risks Associated with Multiple IV Infusions, is being conducted by the Health Technology Safety Research Team at the University Health Network in Toronto, Canada in collaboration with ISMP-Canada. The nine recommendations in this paper are from an interim report, Multiple Intravenous Infusions Phase 1b: Practice and Training Scan
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Title:  Smart Pump Implementation: A Guide For Healthcare Institutions
Description: The purpose of this document is to guide healthcare institutions through the purchasing and implementation phases of smart infusion pumps and to help institutions that are currently using this technology to assess successful adoption. Study conducted by Health Technology Safety Research Team at the University Health Network in Toronto, Canada.
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