Devices & Diagnostics, Health IT, Hospitals

Healthcare technology news: Alarm fatigue remains top health tech hazard

As technology trends emerge in hospitals they also pose new risks as well. Surgical fires […]

As technology trends emerge in hospitals they also pose new risks as well. Surgical fires may no longer pose the same risk they once did, but the ECRI Institute’s annual top 10 list of healthcare technology hazards highlights other issues. Emerging risks posed by interoperability problems and inadequate planning for electronic medical record implementation offer new sources for concern. Still, alarm fatigue remains the biggest threat. The Joint Commission highlighted alarm fatigue as the cause of 98 sentinel events in hospitals, 80 of them deaths, in a report issued earlier this year.

One of the conclusions drawn in the report is that hospitals need to do a better job of “change management.” That is, changing the way IT projects are defined by making sure physicians, nurses and medical staff in positions to provide useful insights can help IT staff carry out projects with the least disruption.

Here’s the full list

1. Alarm Hazards

2. Infusion Pump Medication Errors

3. CT Radiation Exposure in Pediatric Patients

4. Data Integrity Failures in EHRs and other Health IT Systems

5. Occupational Radiation Hazards in Hybrid ORs

6. Inadequate Reprocessing of Endoscopes and Surgical Instruments

7. Neglecting Change Management for Networked Devices and Systems

8. Risks to Pediatric Patients from “Adult” Technologies

9. Robotic Surgery Complications due to Insufficient Training

10. Retained Devices and Unretrieved Fragments

Alarm fatigue is kind of complex because it happens on a few different levels. Intensive care units in particular are a cacophony of bells and beeps. In responding to one set of alarms, medical staff can get distracted from other critical patient care activities. They can become desensitized and miss important alarms because of too many insignificant alarms.

ECRI offered up its own recommendations to the Joint Commission for goals for the alarm management policy. There was something for hospitals and for medical device companies:

  • Minimize the number of clinically insignificant or avoidable alarms so that the conditions that require attention can be more easily recognized.
  • Optimize alarm response protocols so that the patient receives the appropriate care at the time it’s needed.

Test, test, test that EMR system. It may be an unfair comparison, but HealthCare.gov illustrated in the highest profile way the bad things that can happen when an insufficient enough time is allocated for testing and fixing any problems that arise before the launch of a new system so many depend upon. With EMR, the stakes are much higher since overlooked errors at implementation can put patients’ lives at risk. It undermines confidence and risks creating errors that may not be picked up immediately but can cause problems later.

When it comes to implementing a changeover from a paper-based to electronic medical record system, changing systems or an upgrade, hospitals need to ensure they test it sufficiently. They also need to test it with the associated interfaces (preferably in a simulated setting) to verify that the system is functioning as intended, according to the report. Ensuring the staff members using the system have sufficient training and support is also critical.There also needs to be a system for users to report problems as they are discovered. Among the errors flagged up in hospital settings are:

  • One patient’s data from a medical device or system mistakenly being associated with another patient’s record
  • Clock synchronization errors
  • Copying and pasting of older information into a new report

Beware of unintended consequences of interoperability: The report also calls attention to the risks that updates, upgrades and modifications for one device can pose to other connected devices or systems. Helpfully, it provides some unnerving examples.

  • A facility-wide PC operating system upgrade caused the loss of remote-display capability for a hospital’s fetal monitoring devices.
  • An EHR software upgrade resulted in changes to certain radiology reports, causing fields for the date and time of the study to drop from the legal record.

 

 

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