Clinical alarms warn caregivers of immediate or potential adverse patient conditions. Alarms must be accurate, intuitive, and provide alerts that are readily interpreted and acted on by clinicians in an appropriate fashion. Clinical alarms and their shortcomings have been the topic of numerous studies and analysis in the literature. The Joint Commission on the Accreditation of Healthcare Organizations established a National Patient Safety goal in 2002 to improve the effectiveness of clinical alarms. This goal was removed for hospital organizations in 2004 and incorporated into the standards of the Joint Commission on the Accreditation of Healthcare Organizations. Despite the technological and healthcare improvements related to efforts to meet the National Patient Safety goal, adverse patient events related to alarm system design and performance, care management and the complexity of the patient care environment continue to occur. In 2004, the American College of Clinical Engineering Healthcare Technology Foundation (www.acce-htf.org) started an initiative to improve clinical alarms. This article presents the results of that initiative through reviews of the literature related to clinical alarm factors and analyzes adverse event databases. Efforts to improve alarms through technological, standards, and regulatory means are also reviewed and evaluated. Forums, meetings and a survey of 1327 clinicians, engineers, technical staff, and managers provided considerable feedback regarding alarm issues. Of particular value is the response from nursing staff who represented most of the respondents to the survey. Observations and recommendations have been developed to improve the impact of clinical alarms on patient safety. Future directions are aimed at increased awareness, a focused effort toward the reduction of false alarms, and soliciting all constituents involved in clinical alarms to meet and develop action plans to address key issues.