February 02, 2011 | | Comments 2
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Mac’s Safety Space: Fire alarm standards

Q: It has long been understood that the EOC standards allowed for actual fire alarms to be counted for up to 50% of a facility’s required fire drills. Out of random curiosity, I tried looking up that standard today and was not able to find the information in EC.02.03.03. Does the standard no longer exist or am I looking in the wrong location?

Steve MacArthur: As information documented in The Joint Commission standards, there is no mention of this under EC.02.03.03. I suspect that the concept is derived from the allowance for an organization to use a “real” emergency toward compliance for the emergency exercise requirements; and the 50% figure is derived from the allowance (under EC.02.03.03 EP #3) which requires at least 50% of the quarterly fire drills to be unannounced.

Strictly speaking, you could use actual fire alarms as however many of the required drills so long as you can appropriately document an evaluation of fire safety equipment, fire safety building features, and staff response to fire, during that event.

Generally speaking, in my experience it is very tough to conduct the same level of evaluation for an unplanned event as you can for a planned drill, but that’s not to say that it’s not possible to do so. Ideally, you wouldn’t be having enough actual alarms to meet the minimum of 12 drills that sort out appropriately by shift—that could make for a very chaotic environment. But again, it really comes down to being able to honor the purpose of the drill, which is to evaluate the performance of people, systems and equipment— as long as you have that documented you should be just fine and dandy.

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Filed Under: Emergency managementEnvironment of care

Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. I use real alarms to be less disruptive. Quite often we have ILSM in place doubling the drill requirements.

    I’m always afraid of crossing the line betweent too many alarms thereby casuing staff to become descensitized to the alarms.

    We also have the mangers complete an observer report following each alarm. If we get enough of these back from real alarms we count them as drills.

  2. Real alarms are prevalent at psychiatric hospitals. Especially those facilities that do not use key-activated “institutional” manual pull stations. Consequently, they reliably achieve the required alarm count.

    Night shift exemption (“silent” walk-through drill) is strictly enforced by the leadership at some facilities. However, silent drills do clue you in on actual staff knowledge, and also provides a teaching moment to re-emphasize key points to the newer hospital staff.

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