hazard/jasleen kaur, via Flickr
It’s a new year, and the ECRI Institute has released its Top 10 Health Technology Hazards for 2015 report, highlighting new health technology hazards (and some older, persistent ones) for health care facilities and nurses to keep in mind.
Alarm hazards still posed the greatest risk, topping the list at number one for the fourth year running. But this year, the report focused on different solutions. Often, according to the report, strategies for reducing alarm hazards focus on alarm fatigue—a hazard nurses have long battled. Now, the report recommends that health care facilities examine alarm configuration policies and practices for completeness and clinical relevance. These practices include:
- determining which alarms should be enabled.
- selecting alarm limits to use.
- establishing the default alarm priority level.
- setting alarm volumes.
Repeat hazards that made the list included inadequate reprocessing of endoscopes and surgical instruments (#4), robotic surgery complications due to insufficient training (#8), and, in at #2, data integrity issues such as incorrect or missing data in electronic health records and other health IT systems. For an overview of these hazards, see our posts on ECRI top 10 health technology hazards from 2013 and 2014.
And here’s an overview of new hazards that made the cut, along with some of the report’s suggestions on how to prevent them.
Mix-up of IV lines leading to misadministration of drugs and solutions (#3)
The risk: In the last two years, infusion pump programming errors have been included on the list. This year, however, the report instead focuses on “the tangle of tubing that exists when multiple IV infusions need to be administered to a single patient,” the risk being that a medication or intravenous solution can be delivered to the wrong infusion site or at the wrong rate.
Some recommendations include:
- physically tracing each infusion from the fluid container, and verifying that the patient connector is attached to the correct administration site.
- labeling each infusion line with the name of the drug or solution being infused.
- making connections without forcing or adapting.
Ventilator disconnections not caught because of misset or missed alarms (#5)
The risk: A complete or partial disconnection at any point along the breathing circuit could lead to anoxic brain injury and may be fatal. To prevent this, ventilators incorporate sensors and alarms to warn caregivers when a disconnection occurs. However, such alarms must be set to appropriate levels and must be heard when they sound.
Some recommendations include:
- developing a policy on setting ventilator low-pressure and low-minute volume alarms to levels appropriate for detecting disconnections.
- directing nurses to examine the breathing system to verify that all circuit connections are secure after the patient has been moved.
- assessing whether alarms can be adequately heard in areas where the ventilator is used.
Patient-handling device use errors and device failures (#6)
The risk: A range of patient-handling technologies, such as ceiling-mounted or mobile patient lift designs, lateral transfer aids, and specially designed chairs and stretchers, are available to help reduce the risk of staff and patient injury. However, improper use of these devices, failure to maintain them, or failures associated with the devices themselves can result in injuries.
Some recommendations: The report suggests training caregivers to recognize scenarios that might require the use of patient-handling equipment (such as transferring patients from toilet to chair, for example). Other suggestions include:
- facilitating the proper use of patient-handling equipment for activities that pose a risk of injury to patients or staff by educating staff.
- selecting equipment with weight-bearing limits that match the needs of the population served.
- and establishing responsibility for the timely inspection, preventive maintenance, and repair of this equipment.
‘Dose creep’ (unnoticed variations in diagnostic radiation exposure) (#7)
The risk: Dose creep is a pattern of radiation exposure levels being increased by clinicians over time in an attempt to achieve better image quality in diagnostic radiography. Although this may not cause immediate harm, over time this may affect many patients.
Some recommendations: The first step, says the report, is ensuring a facility’s digital diagnostic radiography systems are equipped to use the standardized exposure index (EI)—as developed by the International Electrotechnical Commission and the American Association of Physicists in Medicine. The EI should be used to estimate the patient dose and exposure on the detector. Facilties should also:
- ensure that EI values are displayed to radiographic technologists as part of their routine workflow.
- install software tools that automatically import and analyze EI data.
- work toward defining acceptable EI values and ranges for commonly performed radiography studies.
Cybersecurity (#9)
The risk: The increasing use of networking and connectivity of medical devices is associated with an increase in the vulnerability of these devices to malware and malicious attacks.
Recommendations include:
- keeping up with the latest updates and patches for operating systems and anti-malware software.
- limiting network access to medical devices through the use of a firewall or virtual LAN.
- auditing the log-in access to all medical devices.
- ensuring that an appropriate password policy is in place.
Overwhelmed recall and safety-alert management programs (#10)
The risk: ECRI experts are concerned that existing hospital recall tracking programs are not keeping pace with the growing number of medical device recalls issued each year. (The FDA reports that the annual number of medical device recalls nearly doubled between 2003 and 2012, from 604 recalls to 1,190 annually.)
Recommendations for facilities include:
- creating a mandate from the top of the organization to facilitate collaboration among alerts management staff and the clinical experts who use, maintain, or manage the technologies in each patient care department.
- designating alert management as a critical patient safety activity.
- and developing a written policy specifying, for example, to whom incoming alerts should be sent, how alerts should be processed, and how the response to those alerts should be documented.
To download the full report for free, visit: www.ecri.org/2015hazards.—Amy M. Collins, managing editor
As a nurse who has spent the last 10 years in industry supporting infusion therapy and patient safety I cannot reinforce one of the recommendations enough– basically if something is difficult to do, such as a connection, it is possibly not something meant to be done!
When working at the bedside I took pride in my McGuyver-like creativity to make things work. Now I realise that most often this puts patients at risk. This is a past publication by the FDA that shows some frightening misconnections. http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM134873.pdf
Engineering fixes can only do so much. Clinicians must be alert and aware at all times to ensure safe care. This may take a few extra seconds or even minutes but it is worth the effort to avoid errors.
This carries over to alarm management. A few minutes at the start of your shift to ensure your ALERTS and ALARMS are appropriate for your patient’s condition at that time will help ensure your care is targeted and captures changes as much as possible. Nuisance noise is everyone’s enemy but I walk into ICU’s and other units with alarms going off all over and no one paying any attention. I have to ask, why have them if they don’t draw the attention they are meant to?