Just because alarm fatigue slipped from the top spot in ECRI Institute‘s annual list of top 10 health technology hazards doesn’t mean it’s no longer a problem in hospitals. It’s just that the Plymouth Meeting, Pennsylvania-based research organization found deficiencies in cleaning of endoscopes that caused ECRI to raise reprocessing of flexible endoscopy equipment to No. 1 on its list for 2016.
“We decided to focus on manual cleaning processes,” said Robert Schluth, senior project officer in ECRI’s Health Devices Group. This was after several fatal cases of the superbug CRE (carbapenem-resistant Enterobacteriaceae) in U.S. hospitals last winter were traced to poor infection control in various scopes.
Still, missed alarms came in at No. 2 for the new year, in no small part because the Joint Commission national patient safety goal to improve the safety of clinical alarms takes effect Jan. 1.
Healthcare providers have been struggling to strike a balance between vigilance and alarm fatigue for years, noted Janet Dillione, CEO of device integration and alarm management company Bernoulli (formerly Cardiopulmonary Corp.).
“It’s not an IT topic. It’s one of those classic interdisciplinary things,” involving clinical, IT and biomedical engineering, said Dillione, who has read the new ECRI report. The hospitals making progress in this area have internal champions in all relevant departments, she said.
Also related to alarm fatigue was the fourth item on the list: inadequate surveillance of patients on telemetry monitors. Schluth explained that monitors are not perfect, particularly when it comes to detecting heart arrhythmias. “Overreliance of what the technology can do could be a problem,” he said.
A new, perhaps surprising, addition to the ECRI top 10 for 2016 is the 10th hazard: malfunctioning medical devices due to improper or overuse of USB ports. Plugging in unauthorized devices into the USB ports on medical devices could lead to security breaches or cause machines to shut down or reboot.
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.
“I consider it an under-the-radar topic,” Schluth said. “It wasn’t a concept that occurred to me until our reports came in,” he admitted.
Schluth said that he has even heard of devices rebooting when clinicians tried charging their phones by plugging them into medical equipment. “We’re aware that problems have actually occurred.”
Workflow matching technology — and vice versa — also remains a safety hazard, according to ECRI. “Workflows haven’t been elegantly solved,” Dillione said. “Processes typically fail at their moments of transition.”
Here is the complete ECRI list of health technology hazards for 2016:
- Inadequate cleaning of flexible endoscopes before disinfection can spread deadly pathogens.
- Missed alarms can have fatal consequences.
- Failure to effectively monitor postoperative patients for opioid-induced respiratory depression can lead to brain injury or death.
- Inadequate surveillance of monitored patients in a telemetry setting may put patients at risk.
- Insufficient training of clinicians on operating room technologies puts patients at increased risk of harm.
- Errors arise when HIT configurations and facility workflow do not support each other.
- Unsafe injection practices expose patients to infectious agents.
- Gamma camera mechanical failures can lead to serious injury or death.
- Failure to appropriately operate intensive care ventilators can result in preventable ventilator-induced lung injuries
- Misuse of USB ports can cause medical devices to malfunction.
Compare these to the 2015 list here.
Image: ECRI Institute
