Alarms triggered by medical devices monitoring patients once again topped a list of patient safety hazards in hospitals, in the second annual report by the ECRI Institute. But instead of alarm fatigue, the report raised concerns about the settings these alarms are placed. It also drew attention to workflow and communication issues such as poor patient handoffs and failure to properly do independent double checks of things like blood type and medication dosages.
“Our accident investigations have found that hospitals have either not had consistent or not had any practices to determine how alarms are set by care area or by patient type,” said James Keller, vice president, health technology evaluation and safety, ECRI Institute. “It doesn’t make sense to use the same default alarm settings in pediatric intensive care as in adult intensive care.” But the report found many hospitals lack a policy to adjust alarm default settings by care area.” It also found a gap in hospital policies failing to specify when and who can make adjustments to the default alarm settings, Keller said in the report.
Most of the alarm-related adverse events ECRI has recorded are traced back to alarms that weren’t configured properly, the report found.
As part of the Joint Commission’s National Patient Safety Goal on clinical alarm safety, organizations accredited by the group have a deadline of 2016 to establish policies and procedures to manage alarm signals identified as essential for patient safety.
EHR data integrity issues are also an increasing area of concern. Hospitals have invested a considerable amount into these systems but they’re finding that mundane errors are the source of a certain number of problems. The fact that so many people have easy access to this data in care settings because it is digital means these errors can be amplified.
Another factor that plays a role is the increasing complexity of healthcare technology and the reliance of that technology to deliver healthcare, Keller noted.
Some of the EHR problems hospitals have encountered, according to the report, include:
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 patient’s data appearing in another patient’s record;
- Missing data or delayed data delivery;
- Clock synchronization errors between medical devices and systems;
- Default values being used by mistake, or fields being pre-populated with erroneous data;
- Inconsistencies in patient information when both paper and electronic records are used;
- Outdated information being copied and pasted into a new report.
As a way to address some of these issues, the report recommends encouraging healthcare staff to report any health IT problem they encounter and use training to help staff better understand that the source of problems like medication errors can be the hospital’s EHR system.
Poor communication tends to be at the heart of errors when it comes to patient handoffs to different departments for procedures. The report recommends
a standardized process for patient transport and handoff communication to reduce errors, including from the place the patient is sent to where they are received. In one harrowing example of the types of things that can go wrong, the report cited the case of an infant who was transported from the OR to the neonatal intensive care unit in an open crib following surgery. Staff in the unit had not been told that the infant’s body temperature had dropped in the operating room, or where the infant had been transported from — the OR — and that the infant had not been monitored in a recovery unit. The report noted:
A nurse preparing the infant for the NICU stay expressed concern about the infant’s pale coloring and slowed respiration. The baby was given vigorous spinal stimulation in an effort to restore breathing and return body temperature to normal, and required intubation when breathing did not fully respond to the spinal stimulation.
The report gleans insights from patient safety reports that healthcare organizations voluntarily send ECRI Institute — a federally accredited patient safety organization. It aggregates analyzes ad shares the findings of these reports to improve awareness of these hazards and recommend ways to avoid them. It claims to have collected nearly 500,000 of these reports from 2009 to the end of 2014. PSOs were set up as part of the Patient Safety and Quality Improvement Act.
Here’s the full list of patient safety hazards as ECRI sees them:
1. Alarm hazards: inadequate alarm configuration policies and practices
2. Data integrity: incorrect or missing data in EHRs and other health IT systems;
3. Managing patient violence;
4. Mix-up of IV lines leading to misadministration of drugs and solutions;
5. Care coordination events related to medication reconciliation;
6. Failure to conduct independent double checks independently;
7. Opioid-related events;
8. Inadequate reprocessing of endoscopes and surgical instruments;
9. Inadequate patient handoffs related to patient transport;
10. Medication errors related to pounds and kilograms
