Every year the ECRI Institute assembles a top 10 list of healthcare technology hazards that cause the most adverse events or, more frequently, near misses jeopardizing patient safety. Although alarm fatigue and electronic health record pitfalls have made repeat appearances on the top 10 list, this year the report took a more in-depth approach to highlight some of the things that contribute to these and other problems. Think “inadequate alarm configuration policies,” “incorrect or missing data from EHRs,” and “mixup of IV lines” and “inadequate reprocessing of surgical equipment.”
The main problem it identifies with the configuration of alarm systems is that the default settings are selected at the hospital without considering which alarms should be enabled, selecting the alarm limits to use, and establishing the default alarm priority level. The report notes that the folks who configure the settings take into consideration factors like the patients’ needs, care area and clinical indications the acuity of the patients. It recommends making one person or a select few responsible for determining the default settings. Hospitals should also make sure staff are trained on the policy and occasionally retrained.
Among the examples the report identifies with missing EHR data are:
- A mismatch of one patient’s data with another patient’s record;
- Missing data or delayed data delivery due to network limitations, data entry delays or configuration errors;
- Clock synchronization errors between different medical devices and systems;
- Default values being used by mistake, or fields being prepopulated with erroneous data;
- Inconsistencies in patient information when both paper and electronic records are used; and
- Outdated information copied and pasted into a new report.
One of the biggest complexities of reporting these problems is that front-line caregivers may not realize that these problems are caused by computer errors — they might think it’s a miscommunication or something else. The report recommends using the Common Formats system developed by the Agency for Healthcare Research and Quality. It has a standard format for reporting health IT-related problems. ECRI’s Patient Safety Organization developed a Partnership for Promoting Health IT Patient Safety. It’s designed to identify safety issues “within a nonpunitive learning environment” to improve health IT for patient safety.
The report also recommends assessing clinical workflow before new systems or modified systems are activated. The idea is to have a better understanding of how the system will be used by frontline staff, and to identify problems and their potential sources. It also advises creating ways to report and investigate incidents, near misses, and hazards associated tied to health IT both within the organization, and to ECRI.
Patient handling devices can be a source of injuries for patients as well as staff. This can include devices to help transfer a patient from a guerney or wheelchair to a bed or vice versa. Although device failures can be a problem, it’s also critical that staff inspect this equipment and maintain it. They also need to flag up and fix problems that can cause injuries. “Equipment that is worn, broken, or defective; that hasn’t been cleaned; or that has a battery that has not been adequately charged either won’t be available for use when needed or could cause patient or staff injury,” the report said.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
One of the new additions to the list this year was recall management, according to the report. It notes that hospital staff need to do a better job of distributing recall information, responding to recall alerts and mapping a strategy for responding to them rapidly enough so that it doesn’t pose a risk to patient safety. “A well-designed and effective recall and safety-alert management program will reliably help staff identify and address defective devices — and other sources of danger or difficulty involving medical technologies— before patients are harmed.”
One of the biggest contributors to this problem is that the annual number of medical device recalls has been climbing. Between 2003 and 2012, medical device recalls nearly doubled from 604 recalls to 1,190 annually, according to FDA data cited by ECRI.
Here is the whole list:
1. Alarm hazards: Inadequate alarm configuration policies and practices
2. Data integrity: Incorrect or missing data in electronic health records and other health IT systems
3. Mix-up of IV lines leading to misadministration of drugs and solutions
4. Inadequate reprocessing of endoscopes and surgical instruments
5. Ventilator disconnections not caught because of mis-set or missed alarms
6. Patient-handling device use errors and device failures
7. “Dose creep”: Unnoticed variations in diagnostic radiation exposures
8. Robotic surgery: Complications due to insufficient training
9. Cybersecurity: Insufficient protections for medical devices and systems
10. Overwhelmed recall and safety alert management programs
You can get a copy of the report by following this link.
