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Alarm hazards, dose errors remain atop ECRI hazards list

Each year, the ECRI Institute releases its top 10 health care technology hazards to shed light on device-related risks and overall health dangers.

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With the health care industry moving toward increased adoption of technology, organizations must be ready for the safety implications that come with it. "I would say that the biggest change has been the rapid and even rushed adoption of HIT-related technologies," said James P. Keller, Jr., vice president of health technology evaluation and safety at the ECRI Institute, in an email to SearchHealthIT.com. "There's definitely a concern that the rush to adopt this technology can cause serious problems."

In order to make the list, a technology hazard must fulfill one of the following criteria

  • It has resulted in injury or death.
  • It occurs frequently.
  • It can affect a large number of individuals.
  • It received high-profile or widespread news coverage.
  • Steps must be in place that hospitals can now take to minimize the risks.

There are a few changes between the 2012 and 2011 technology hazards list. All points, however, are noteworthy for health care organizations.

After placing no. 2 in 2011, alarm fatigue tops 2012 technology hazards list

Alarm fatigue occurs when caregivers are overwhelmed by the number of alarms that monitors such as ventilators, infusion pumps and dialysis units produce and become desensitized to them. This phenomenon can result in increased adverse events -- slower response times, failure to return alarms to active settings post standby mode, staff making modifications (such as alarm volume) without other staff knowing and, as a result, other staff being unable to differentiate urgency levels due to those changes.

Some alarms, however, will keep sounding until staff intervenes. "Alarms on monitors usually will re-alarm after being silenced, until the issue is resolved, and overall monitors have become enormously more sophisticated in their ability to report specifics and to avoid alarming when they shouldn't," said Scott R. Fisher, M.D., a physician informaticist and physician adoption consultant who currently serves as program director for clinician adoption at Children's Hospital Los Angeles.

For example, if an EKG electrode is disconnected, the monitor will display a specific alert for caregivers such as "lead fault" said Fisher, adding that monitors as a whole "used to be smart enough to do this."

One of the focal points of health IT is the adoption of electronic health record (EHR) systems. At this point, there's a difference of opinion on how alarms aid caregivers using EHR.

"I think it's a little early for much patient monitor-based alarm data to be used in the EHR," Keller said. "We'll need to first tackle the problem of getting devices and HIT systems to effectively talk to each other first."

On the contrary, Fisher contended, "EHRs have had built-in alarms since their inception. In my opinion, the biggest challenge here is trying to program the computer system to think like a physician, which exceeds our abilities for now, at least in areas like this."

The ECRI report recommends health care organizations take a few measures to improve alarm efficiency -- namely, create a multidisciplinary team, review recent events and near-misses and identify patient safety vulnerabilities. Most hospitals deal with alarm fatigue by limiting the alarms to severe cases, said Fisher, who recommends that organizations "turn off all the alerts completely for the first few weeks or months, while [doctors] get used to the system as a whole."

Radiation, other dose errors, tops in 2011, now no. 2

Radiation is used to kill tumors in patients but can be hazardous when it's not administered correctly. Inaccuracies in radiation levels can negatively impact healthy tissue and organs.

There is no set definition of a reportable radiation-related event. What's more, adverse events related to radiation could be underreported as a whole.

Improving radiation therapy efforts can be accomplished by ensuring staffing levels are adequate, committing caregivers to a nationally recognized accreditation certification program and guaranteeing that quality control procedures are in place, the report noted.

Infusion pump administration rises to no. 3 among technology hazards

Some patients are sensitive to the medication they receive from infusion pumps. This places extra pressure on caregivers, who import and program medication administration levels. Specifically, it requires caregivers to fill in correct fields and avoid any typos.

Although technology advancements such as smart pumps have increased safety, limiting adverse events starts by examining the entire infusion pump process. Purchases, for example, should be considered in the context of an overall medication delivery system, Keller said, since pumps are likely to become integrated with a variety of information systems.

Another important step for caregivers, Keller said, is looking closely at the drug libraries that the organization uses for its various clinical areas and asking, "Can those libraries be consolidated into one database that can be easily uploaded to the pumps you are considering?"

Surgical fires remain weekly occurrence, reach no. 7

The ECRI Institute receives reports on one or two surgical fired per week, or nearly 600 each year. Not all fires result in patient harm. However, when a patient is harmed, the outcome can be disfigurement or even death.

Fisher has never witnessed to a surgical fire in more than 20 years of operating room experience. In the past, he said, flammable anesthetic agents such as ether and cyclopropane were the likely culprits. Today's problems, Fisher said, are mostly related to electrocautery and, to a lesser extent, the use of laser in the operating room." He added that there are still fire codes that dictate electrical standards for operating room equipment.

Poor usability of patient medical devices rounds out technology hazards list

I would say that the biggest change has been the rapid and even rushed adoption of HIT-related technologies.

James P. Keller, Jr., vice president, health technology evaluation and safety, ECRI Institute

Personal medical devices and telepresence technology are gaining traction in today’s health care industry, especially for chronic illness management and prevention. Technology hazards often arise due to a lack of direct patient and device supervision, the report said, which increases the risk that errors could occur. Additionally, many devices are just as complex as those found in the hospital. Overmatched by the equipment's complexity, patients and caregivers alike can use the devices incorrectly.

The FDA has expressed concern about medical devices used at home, launching an initiative to raise awareness on the 7.6 million patients in the U.S. who use home health to some extent. They focus on three challenges -- caregiver knowledge, environmental unpredictability and medical device usability.

Furthermore, the FDA has shown apprehension toward devices that are outdated, lack labels or instructions, or include instructions that are difficult to comprehend. Lastly, the FDA noted that patients cannot choose the device they want; instead, they are often limited to what is prescribed to them or what their insurance covers. All of these issues can lead to adverse events, which can also be reported to the FDA.

ECRI recommends that provider assess patients and caregivers before prescribing any medical device, in order to ensure that patients can use the equipment correctly. Additionally, patients should be consistently reassessed, as well as "any time the patient experiences a clinical event." Finally, all patients should receive clear educational materials and directions.

The ECRI Institute has developed a Web-based survey tool to help hospitals perform a risk assessment related to each of the 10 technology hazards. However, the tool is only available to members of ECRI Institute's Health Devices System.

Let us know what you think about the story; email Craig Byer. Assistant Editor.

This was first published in December 2011

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