Healthcare leaders should be on special alert for three serious hazards that increasingly threaten both patients and providers with harm, says the ECRI Institute's Top 10 Health Technology Hazards report for 2013.
The three hazards involve electronic health records, health information technology systems, and cell phones and other mobile devices, which can distract healthcare providers from the focus they need for tasks at hand many times an hour.
As healthcare organizations gain experience with IT systems, they’re encountering ways in which technology can introduce mistakes with far-reaching consequences. For example, simple errors may result in one patient's test results or prescription orders finding their way into another patient's medical record.
"The biggest thing we hope will come of our report this year is that healthcare organizations start to pay closer attention to healthcare technology safety," says Jim Keller, the institute's vice president for health technology evaluation and safety.
He adds that the authors of the report "felt that safety with healthcare technology has been given short shrift, or not really considered at all. But by having a 'top 10 hazards' list, healthcare organizations can look to that to help them prioritize safety initiatives that we think are important to have in place."
This year's ECRI Institute report, the sixth in an annual series, is longer than previous versions and contains specific examples of medical errors and mishaps. Each of the 10 sections also includes recommendations for what organizations can do to prevent such incidents.
"We'd gotten commentary from folks that they would appreciate more background on each of the top 10 topics," Keller said.
One reason for the added length and detail, he explained, is because more hospital organizations are joining patient safety organizations that are collecting such specific information.
The PSO legal framework, implemented three years ago, allows providers to log information about all sorts of adverse events, near misses, and unsafe conditions in an environment that is protected from legal discovery or pubic record disclosure. That information can be collated, catalogued and shared with all organizations participating in safety initiatives.
"With a significant growth in the number of hospitals participating in PSOs, particularly with the ECRI institute, we've been able to draw on a richer set of data to help build up this top 10 list for this year," Keller says.
The 2013 ECRI report expands on an Institute of Medicine's report that called last year for greater attention to the ability of health information technology and electronic record systems to introduce errors into the process.
"Designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of healthcare, which can lead to unintended adverse consequences, for example dosing errors, failure to detect fatal illnesses, and delayed treatment due to poor human–computer interactions or loss of data," the IOM authors wrote.
The top 10 ECRI-identified hazards are ranked in an order that factors in:
- The extent of potential harm
- The likihood the hazard will occur
- How many people it might affect in how many facilities
- The difficulty such an error or problem is to recognize and quickly correct before "a cascade of downstream errors"
- The likelihood that media or other pressures may force a rapid and conspicuous management
They are:
1. Alarm hazards.
Beeping, buzzing, and ringing from ventilators, pumps, dialysis machines and other patient monitoring devices has created a much reported alarm fatigue. Providers are only human, and when too many alarms go off, caregivers "may turn down the volume of alarms to an inaudible level, or they may improperly adjust alarm limits outside the safe and appropriate range."
The report describes an initiative at Johns Hopkins in which a study of all the different alarms resulted in a modification of alarm thresholds to reduce the "non-actionable, clinically insignificant alarms," by 43%. Alarm hazards has been in ECRI's top 10 hazards list's first or second place for the last three years.
2. Medication administration errors using infusion pumps.
Infusion devices contribute more adverse incident reports to the U.S. Food and Drug Administration than any other medical technology, with often severe consequences. Between 2005 and 2009, the FDA received reports about 710 infusion-pump error deaths.
One solution is the integration of infusion pump performance with electronic ordering, administration and documentation systems, which could avoid 75% of certain events.
3. Unnecessary exposures and radiation burns from diagnostic radiology procedures.
ECRI has expanded this category from radiation therapy and CT scan overexposure hazards, which ranked high for the last two years, include to diagnostic radiology procedures.
"We are recommending that healthcare facilities look more broadly at the many factors that can contribute to unnecessary radiation exposures—or, in extreme cases, cause radiation burns—with any diagnostic imaging modality," the report says.
Providers should ask if the images are really necessary, and if so, whether the doses needed to get the image as low as reasonably achievable, the report suggests.
4. Patient data mismatches in electronic health records and other health IT systems.
EHR mismatched data errors don't necessarily happen because of carelessness or user error, but could result from design flaws or software anomalies. "If the problem is one that is not easily discoverable, many patients could be affected before the defect is found," the report says.
Precautions should be taken to avoid errors resulting from network outages. For example, a system may continue recording information from a patient monitoring device during the outage, but if the device is moved from one patient to another, "the stored information could be sent to the wrong patient's record once the network comes back online."
5. Interoperability failures with medical devices and heath information technology systems.
The report notes a surprisingly frequent problem in which interfaces between medical devices do not work. "When testing connectivity between physiologic monitoring systems and ventilators, we found that most of the interfaces we tested did not function as desired—and some even allowed dangerous conditions to exist."
"For example, one monitoring system did not communicate audible or visual alarms from an interfaced ventilator to warn caregivers of a critical patient circuit disconnection, a condition that would result in the patient no longer receiving respiratory support."
6. Air embolism hazards.
Appearing on the ECRI hazards list for the first time, the problem of air embolisms may be increasing with potentially fatal consequences because of the expanding types of technology that may create opportunities for them to occur.
For example, the report says, automatic contrast media injectors for radiologic procedures, central venous access devices, and pressurized spray devices for applying fibrin sealants for blood clotting may result in the need to resuscitate patients.
7. Inattention to the needs of pediatric patients when using "adult" technologies.
When adult technologies are used on children without appropriate modifications or dosage reductions harm may occur. Radiology is one example, where an adult dose of radiation, or overuse of imaging scans, may cause cancer in a child.
8. Inadequate reprocessing of endoscopic devices and surgical instruments.
Listed for the third consecutive year, inadequate cleaning of endoscopic devices and surgical instruments continues to plague healthcare settings.
For example, the report detailed several incidents in which surgeons found potentially contaminating substances such as blood in equipment they needed to use during invasive procedures, such as a scope, a cannula, or instruments placed on a tray in a sterile field before surgery.
9. Caregiver distractions from smartphones and other mobile devices.
Personal devices provide an increasing number of opportunities for healthcare practitioners to distract themselves from tasks at hand and make mistakes in the process.
"Half of respondents to a 2010 survey of perfusionists acknowledged texting during heart-lung bypass procedures, with 15% further acknowledging that they accessed the Internet, and 3% reporting that they visited social networking sites during procedures," the report says.
It recommends that organizations develop mobile management strategies and consider restricting personal use of smartphones and other devices during patient care.
10. Surgical fires.
On the list for the third year in a row, surgical fires still occur, especially in oxygen-enriched healthcare units, and "more frequently than many people realize—despite the availability of effective guidance for fire prevention," the report says.
The report recommends that surgeons conduct surgical team time-out interludes before each case specifically to look for fire risks.