Fire Alarm System Pull Station Activation Mandatory

Did you know that when performing one of your quarterly fire and emergency drills you have to document that you have demonstrated the protocol for the activation of your fire alarm system/pull station and complete evacuation of the entire facility. 

Make sure you know where your key is to the pull station so you can turn off the alarm after your drill.

For free-standing surgery centers:

  1. If you choose to you can let neighboring businesses know a week ahead of time that your center is going to have a fire drill to test the functions of the alarm systems. 
  2. The day of the drill call in to your fire alarm monitoring company and ask that you be taken off-line.  Let them know you are about to have a fire drill and you will call them back to check that they did receive the signal and at what time.
  3. The Safety Officer of the center should pull the pull station fire alarm.  The alarm should sound.  If you are Medicare certified you should see strobe lights flashing as well.
  4. All staff members must perform the evacuation RACE protocol.
  5. Front office staff must be aware of how many individuals are in the waiting area.  Upon hearing the alarm make a head count and instruct all occupants to the nearest exit.  Ensure all waiting area occupants walk safely and keep to one side to evacuate the building and proceed to a safe refuge area.
  6. Any occupant in the waiting area with a physical disability should be assigned to a front office staff member.  For example a man in a wheel chair should have assistance in exiting the building. 
  7. The scrub person is responsible for shutting off all medical gas (es), equipment; assist nursing staff with securing and escorting PACU patients to safety and closing all doors as you exit out of the center.
  8. The Operating Room RN, Anesthesia Provider and Surgeon are responsible to secure and escort the Operating Room patient to safety.  Nursing staff in PACU (recovery) is responsible to secure and escort the recovering patients to safety.  Make sure that your center is always appropriately staffed. 
  9. Safety Officer will make the judgment call as to whether or not they will roll/carry out the crash cart to the safe refuge area.

Once you have reached the designated safe refuge area outside the building perform your head count.  After the Safety Officer has accounted for everyone it is the responsibility of the Safety Officer to go back inside to turn off the alarm.  The Safety Officer will proceed to call the fire alarm monitoring company and obtain the exact time that the signal was received.  Remember to document all of this information including how long it takes for everyone to evacuate the building. 

If you are in a medical building with multiple storey (s) it is mandatory for the building management to orchestrate the fire alarm system/pull station drills.  You should receive bulletins from management for participation in these drills.  If you don’t I highly recommend you call building management and ask them to provide you with the fire alarm monitoring reports especially if you are Medicare certified.  Then perform a MOCK drill and attach the fire alarm system monitoring reports to your drill. For more information on what types of drills are required for surgery center accreditation and certification please refer back to this post and this one too.

Fire Alarm System Activation
Don’t forget to activate the fire alarm system pull station.

Here’s to your success,




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