Hospira Symbiq infusion pump
Hospitals should pay particularly close attention to potential errors related to large-volume infusion pumps, an influential device-testing company has advised.
ECRI Institute of Plymouth Meeting, Pennsylvania, named infusion errors as No. 1 on its annual list of healthcare technology hazards. The testing lab and safety investigator released its “Top 1o Technology Hazards for 2017” report on Monday.
“Although today’s pumps incorporate features that reduce the risks of infusion errors, these safety mechanisms cannot eliminate all potential errors, and the mechanisms themselves have been known to fail,” the company said. “ECRI Institute continues to receive reports and investigate incidents of uncontrolled flow of medication to the patient—a potentially fatal circumstance known as “IV free flow”—and other infusion errors.”
Hospital staff could have prevented many of the incidents ECRI identified by noticing physical damage to infusion pumps and related components, making better use of the roller clamp on IV tubing or checking the drip chamber under the medication reservoir for signs of free flow, the report said.
It’s a somewhat surprising No. 1 choice, as errors related to infusion pumps haven’t really been in the news in a while. The Food and Drug Administration issued an alert in August 2015 that warned of a hacking risk in Hospira Symbiq infusion pumps. Hospira has said it is phasing out the Symbiq line in favor of newer models, but the issue of pump errors seemed to be less prominent in 2016.
“We had a lot of really interesting discussions about it,” said Rob Schluth, senior project officer in ECRI’s Health Devices Group. “We kept coming back to that one,” based on reports from clients.
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Many of those clients were not even aware of the safety risks related to infusion pumps, which is one reason ECRI decided to highlight this issue. “That was exactly our point,” explained Erin Sparnon, engineering manager of the Health Devices Group.
Sparnon said many hospitals stopped even thinking about drip chambers because infusion pumps have had those safety features for decades.
A year ago, reprocessing of flexible endoscopy equipment took the top spot. The FDA had to issue a safety warning in February 2015 about bacterial infections in duodenoscopes. This issue dropped to No. 2 for 2017.
A previous No. 1, alert fatigue — specifically as it relates to ventilator alarms — fell to the third spot for 2017 after coming in second on the 2016 list. Alert fatigue has been at or near the top of list for all 10 years ECRI has produced the rankings.
“Alarms are ubiquitous. They’re going off every minute of every day,” Schluth said. “Ventilators seem like the next area that warrants attention,” he added.
Those results do not mean the problems of alert fatigue or endoscopy reprocessing are any less serious now than in the past. ECRI starts from scratch in compiling its top 10 each year.
“Obviously, we think a lot of work needs to be done,” Schluth said of scope contamination.
Here is the complete ECRI list of health technology hazards for 2017
- Infusion errors can be deadly if simple safety steps are overlooked.
- Inadequate cleaning of complex reusable instruments can lead to infections.
- Missed ventilator alarms can lead to patient harm.
- Undetected opioid-induced respiratory depression.
- Infection risks with heater-cooler devices used in cardiothoracic surgery.
- Software management gaps put patients, and patient data, at risk.
- Occupational radiation hazards in hybrid ORs.
- Automated dispensing cabinet setup and use errors may cause medication mishaps.
- Surgical stapler misuse and malfunctions.
- Device failures caused by cleaning products and practices.
ECRI Institute said every one of the issues raised is preventable, or at least can be mitigated with better technology management. “In this way, the list serves as a tool that healthcare facilities can use to prioritize their patient safety efforts,” the report said.
Photo: Hospira
