For all the benefits of health technology, like speed, efficiency and effectiveness, it’s not perfect. A report by the ECRI Institute outlines what it sees as the biggest concerns for 2012 using criteria such as — can it kill, how frequently does the threat present itself and is it widespread?
1. Medical devices equipped with alarms. How ironic that alarms top the list of health technology hazards. But these systems are the most critical. In a hospital setting, alarms go off all the time but there is a risk of some hospital staff becoming desensitized to the constant beeps and in the worst cases — turning the sound down. Medical staff need to be trained as to the different levels of alarms and how to differentiate between what’s urgent and what’s not. Hospitals can system-wide protocols for alarm system settings on all equipment used for patient care and how staff respond to these alarms.
2. Exposure from radiation therapy. Hospitals should audit the levels of radiation doses for CT studies, which are being used more frequently, as there is a tendency to increase radiation to get better images. The Joint Commission’s Sentinel Event issued an alert in August titled “Radiation Risks of Diagnostic Imaging.”
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3. Infusion pumps and administration errors. A lot of different medical staff are processing directions, creating potential sources for errors such as misread handwriting, incorrectly prepped drugs and solutions, or medication being given to the wrong patient. An infusion device summit held in October 2010 by the FDA and AAMI grouped hundreds of different types of pump issues into 13 “clarion themes” and launched an Infusion Device Safety Council.
4. Flexible endoscopes and cross-contamination. These devices have the potential to contaminate a large group of people so it’s critical to follow established protocol for cleaning and disinfecting/sterilizing guidelines and instructions after each use. The ECRIO Institute published a set of guidelines for preventing cross-contamination.
5. Interconnected medical technology and IT systems. For as many reasons why this is a good thing, there is inevitably a downside. The report points out that one key reason problems crop up is the failure to implement adequate change management policies and procedures that accommodate both IT and medical technology needs. It’s important for healthcare staff to be aware that the interconnectedness of medical medical devices and health IT can create a possible “domino effect” in which changes to one device affect the other.
ECRI advises healthcare facilities to test every software upgrade before it is implemented to prevent this problem from occurring. One facility found that with each software update there are one to three issues that must be resolved before the software upgrade can be distributed, according to the report. “Care should be taken to determine how technology decisions involving medical devices and IT networks can affect current operations, patient care, and clinician work processes.”
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6. Feeding tube misconnections. This can happen when nutrients for the GI tract accidentally delivered somewhere else in the body and inappropriate fluids are inadvertently delivered to the GI tract, creating a life-threatening situation. Despite a national standard being introduced in 2005, it is voluntary. Last year the FDA highlighted the dangers associated with misconnections in a letter to manufacturers, healthcare professionals and purchasing departments called for manufacturers to adopt safety measures such as a color coding or building “designed incompatibility” into their products to help reduce or prevent misconnections.
7. Surgical fires. The ECRI Institute estimates there are 600 surgical fires in the US each year. Oxidizers, ignition sources,
and fuels in the operating room are some things to consider. ECRI published a whitepaper on the subject in 2009.The FDA collected all the information it has on surgical fires into one section of its website last month.
8. Needles and sharp objects. This is a fear for many people as soon as they are old enough to get their first vaccine but it’s also a very real hazard for healthcare staff and patients. Exposure to blood born pathogens and HIV can pose serious threats in these instances. The Centers for Disease Control and Prevention estimates that 385,000 sharps-related injuries occur annually among health care workers in hospitals. Its website highlights data from the Exposure Prevention Information Network to prevent and reduce sharps injuries as part of the Centers’ “Stop Sticks” campaign.
9. Anesthesia. Hospitals routinely conduct pre-use inspections for anesthesia units before surgery but sometimes this inspection system can be flawed — it can be incomplete or inconsistent, for example. Among the ways to address this, ECRI advocates a methodical check of the unit, everyone knowing which staff member(s) is doing the inspection, and having a hard copy of a checklist for any manual procedures that need to be done as part of the inspection.
10. Home-use medical devices. With a growing elderly population combined with more people living with chronic health problems, 7.6 million people receive home healthcare, according to the FDA. Awareness of the proper use of medical devices at home is critical. Devices that are used in the home are not typically designed with non-healthcare professional users in mind. Devices used at home are typically older and may lack proper labeling, according to the FDA. Also, some devices ordered from the Internet may not include proper instruction.
