16 TECH HAZARDS “Technology safety can often be overlooked,”
says James Keller Jr, vice president, health technology evaluation and safety, ECRI Institute. “Based on our experience, there are serious safety problems that need to be addressed. ECRI Institute recommends that hospitals use our list as a guide to help prioritize their technology-related safety initiatives.” The 2015 Top 10 Health Technology Hazards
report, available for download as a free public service, details a variety of technology hazards that put patients at risk. For the fourth year in a row, clinical alarm hazards, a Joint Commission National Patient Safety Goal, remains number one on ECRI’s list. This year, the report draws particular attention to alarm configuration practices. ECRI Institute is aware of several deaths and other cases of severe patient harm that may have been prevented with more effective alarm policies and practices. Recall management, which appears on the list
for the first time, points to overwhelmed recall and safety-alert programs as a potential for serious consequences for healthcare facilities and patients. 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 Food and Drug Administration reports that the annual number of medical device recalls nearly doubled between 2003 and 2012, from 604 recalls to 1,190 annually. To develop the annual list, ECRI Institute’s
multidisciplinary staff of engineers, scientists, nurses, physicians, and patient safety analysts drew on the resources of the Institute’s 45-year history, as well as expertise and insight gained through testing and analyzing healthcare technologies. This includes examining health technology-related problem reports from hospitals and health systems worldwide, and reports received through ECRI Institute Patient Safety Organization. Here is a summary of the report’s main findings and recommendations:
1. Alarm hazards The report argues that while many strategies for reducing alarm hazards focus on alarm fatigue—whereby staff miss alarms as they are overwhelmed or desensitised by the sheer number of alarms that activate—there are other factors also at play. “In ECRI Institute’s experience, alarm-
related adverse events—which can involve missed alarms or unrecognized alarm
conditions—can often be traced to inappropriate alarm configuration practices,” it states. It goes on to give detailed recommendations for establishing a policy describing care area- specific standard alarm configuration practices. “If a policy already exists, assess the policy for completeness and clinical relevance,” it adds.
2. Data integrity Incorrect or missing data in electronic health records and other health IT systems is a major problem in healthcare. “What makes this problem so troubling is that the integrity of the data in health IT (HIT) systems can be compromised in a number of ways, and once errors are introduced, they can be difficult to spot and correct,” states the report. It recommends that before implementing
a new system or modifying an existing one, it is important to assess the clinical workflow to understand how the system is (or will be) used by frontline staff, and identify inefficiencies as well as any potential error sources. The system should be thoroughly tested and
staff should be comprehensively trained. A reporting system for HIT-related incidents and near-misses should also be in place.
3. Mix-up of IV lines leading to misadministration of drugs and solutions The report highlights the risks surrounding the tangle of tubing created when multiple IV infusions need to be administered to a single patient—a common occurrence in healthcare. “If a medication or IV solution is delivered
to the wrong infusion site, or at the wrong rate, the consequences can be severe,” it states. It recommends that for all instances in which multiple IV infusions need to be administered to a single patient, staff should (i) physically trace existing lines from source to site, and verify that the patient connector is attached to the correct administration site; (ii) label each infusion line with the name of the drug or solution being infused; and (iii) make connections without forcing or adapting.
4. Inadequate reprocessing of endoscopes and surgical instruments When reprocessing is not performed properly, pathogens can be spread to subsequent patients, potentially leading to hospital-acquired infections or the spread of disease. “One critical reprocessing step—one that
is sometimes overlooked or inconsistently performed—is the initial cleaning of the device or instrument at the site of use (eg, in the procedure
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“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.”
room). If organic soils and other contaminants are not first removed, successful disinfection or sterilization of the device or instrument may not be possible,” states the report. It adds that the intricacy of some instruments
can add a further layer of complication. It makes a number of recommendations for ensuring reprocessing is done properly, including the provision of adequate space and resourcing for reprocessing, and fostering communication and collaboration between reprocessing personnel and the departments they support.
5. Ventilator disconnections not caught because of mis-set or missed alarms A complete or partial disconnection at any point along the breathing circuit—the pathway
HRMR January 2015
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