Top 10 Health Technology Hazards for 2013
Patient care research firm ECRI Institute recently published its sixth annual list of the Top 10 health care technology hazards, including several related to information technology. The comprehensive report explains the hazards and gives multiple recommendations for each, as well as links to additional resources.
Monitors, pumps, dialysis units and many other devices trigger alarms when potential problems are detected. The sheer number of alarms itself is a problem, as caregivers can become desensitized to them. Alarm management, including protocols, can ensure only desired alarms are forwarded to the clinician. Giving a visual or audible priority level of each alarm also can aid in clinical decision making.
Infusion devices are the subject of more adverse incident reports to the FDA than any other medical technology, ECRI reports. Smart pumps can reduce programming errors. Another major safety enhancement is integrating pumps with electronic ordering, administration and documentation systems. Checking programming against orders can cut 75 percent of such errors, an ECRI analysis shows.
There is a tendency to use higher radiation doses because image quality improves. But the price could be a higher long-term risk of cancer. Providers should consider if imaging techniques that dont rely on ionizing radiation can give the needed diagnostic information. They also can check if acceptable images were recently acquired to prevent repeated exposure.
Patient/data association errors using IT can result from flawed system designs or software anomalies, and may not be discovered until many patients are affected. Health IT systems can multiply these problems much more than paper-based systems. Reducing such errors should be a priority in the planning and early implementation stages of an IT project. For instance, data transfer between a medical device and an EHR is a priority area to study, as mismatches can occur when an EHR that was down comes back up.
Attention to broader device/IT interoperability issues beyond patient/data association also are necessary. Interfaces between devices may not work as intended. Research of interfaces between physiologic monitoring systems and ventilators found that most did not function as desired, and may result in necessary alarms not being triggered. New work on IT systems can affect existing links between devices and systems, so the changes should be made in a controlled manner. An updated inventory of interfaced devices and systems, including the software versions and configurations, also can minimize risk.
Intravascular air embolism is a well-known hazard, but it still happens and periodic renewed attention within a patient safety program is warranted. A time-out procedure to double-check before procedures with a high embolism risk should be instituted, as well as tracing any line to its source before connecting the line to an IV access device. Using carbon dioxide instead of air as the insufflation gas when distending a patients anatomy should be considered.
This is a theme that developed while making the Top 10 hazards list, as sometimes pediatric versions of technology are not available. Radiation dose settings for adults can give excessive levels to still-developing children, and like adults, children are at risk for overuse of imaging. Evidence-based indicators within the X-ray order process can reduce the number of studies performed. Other danger zones include EHRs that dont show height and weight charts on the same screen, use of adult-oriented CPOE systems and emergency care supplies, and oxygen concentrators. Providers should consider having a pediatric patient safety coordinator.
In several previous Top 10 lists, we addressed the cross-contamination hazards that exist when flexible endoscopes are not properly reprocessed, ECRI notes in its report. Alas, these hazards continue, and the organization recommends that providers address the reprocessing function more broadly in their patient safety initiatives. Ensuring that a sufficient number of instruments to meet demand are available will allow adequate time for reprocessing. Short turnaround times can lead to taking risky shortcuts.
What happens when a clinician is entering an order via a smartphone into the CPOE system and gets a personal text message? The clinician may forget to complete the order. Surveys show large numbers of clinicians have personally witnessed distracted behavior. Education on the potential for digital distractions and developing a mobile device management program, which could include restricting personal use during patient care activities, are two of several strategies that can be employed.
While very rare, this hazard remains on the Top 10 list because of its devastating consequences, and because fires still occur more frequently than believed. With few exceptions, open delivery to the face of 100 percent oxygen should be discontinued for head, face, neck and upper-chest surgery. And a surgical team time-out before the start of each procedure to assess fire risks is a good idea.
The ECRI Institute Top 10 Health Technology Hazards for 2013 report is available at https://www.ecri.org/Forms/Pages/ECRI-Institute-2013-Top-10-Hazards.aspx.
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