Alarms #1 tech risk despite focus, according to ECRI
Annual list also highlights dangers to peds patients
Last year, when alarm fatigue appeared on the ECRI Institute technology hazards list, it seemed to coincide with a push from a lot of organizations to deal with the issue. Indeed, within months of the ECRI report coming out, there was a Joint Commission sentinel event alert and 2014 National Patient Safety goal related to alarm management. But all that attention hasn’t made it any less of a hazard in the eyes of the experts who craft the annual list. This year, it’s number one.
"It is really validating to have what we find an issue and push for to be on the radar is also important to others," says Rob Schluth, senior project officer of the ECRI Institute, who works on the annual list. "We try to highlight what we think people need to pay attention to in the coming year, what is high profile. If it’s something that might land you on the front page of the paper, well, that’s what makes it important to deal with."
The alarm management issue could be one of those front-page issues: In three years prior to the sentinel even alert, The Joint Commission had 98 reports of alarm-related events, 80 of which resulted in death and 13 in permanent loss of function. It’s not just about diminishing noise on a unit.
Schluth says there are "hundreds of places" to look for potential errors, competing priorities, and finite money and time. Creating a list is a practical way to give health care organizations a way to find high-impact gains that can improve patient safety.
Top technology hazards
A group of experts looks at problem report databases, internal evaluations of technology from the internal testing lab at ECRI. They solicit ideas from contacts in hospitals about what they are seeing as potential problem areas and look in the literature to see what people are publishing. After the group creates a master list, it researches the topics and then goes through a voting process to come up with the top 10.
The top technology hazards for 2014 are:
- alarm hazards;
- infusion pump medication errors;
- CT radiation exposure in pediatric patients;
- data integrity failures in EHRs and other health IT systems;
- occupational radiation hazards in hybrid ORs;
- inadequate reprocessing of endoscopes and surgical instruments;
- neglecting change management for networked devices and systems;
- risks to pediatric patients from "adult" technologies;
- robotic surgery complications due to insufficient training;
- . retained devices and unretrieved fragments.
Several of these are new to this year; some are very new. Number 5, related to hybrid operating rooms, is probably something that only the largest and newest of facilities will have to deal with, but the risks are new, unknown, and given the expansion of this technology, potentially growing.
A hybrid operating room is one that has high-end imaging equipment built into the OR setting. "The idea is that you can have a full-scale angiography system to do minimally invasive surgery," says Schluth. "But then if you need to convert to full-scale open surgery in an emergent situation, what happens? What are the risks? And imaging technology has traditionally been used in a separate department. Now you are using it in an environment with staff that may not be as familiar with the risks as the imaging staff. Will they be unnecessarily exposed to radiation?"
Another OR-related item on the list is number 9, related to the training of those who use robotic surgery tools. Most physicians go through training with manufacturers for specific procedures, says Schluth.
But will they then use it for other procedures? Will the person who teaches you a particular procedure have done it before with that particular robot? What does a surgeon have to do to prove he or she can do this particular surgery effectively? Will there be proctoring? Will the whole surgical team have to have experience with the technology, or just the surgeon? Schluth says there are no hard rules for this, which means there is the potential for harm.
Still on a surgical theme is the last item on the list, retained objects. This made the cut in 2009 and 2010 and is back again — at the same time that The Joint Commission has issued a sentinel event alert on the topic. (For more on the Joint Commission Sentinel Event Alert on retained objects, see page 138.) Schluth says that for a couple years, "it didn’t rise to the level to supplant one of the other areas. But now it’s back. It seemed a good idea to put it back on the radar."
While there are recommendations around the issue, and procedures to follow, the passage of time can lead to reduced vigilance, he says. "It’s not news to people, but there are some who may not be aware of the danger. We have an accident and investigation group, and since we last included the topic on the list, we have been contacted for nine investigations of retained objects. Digging around in the data, we found that if you look at the top three reasons for malpractice cases, retained objects are implicated in half of them." Add in the sentinel event alert, and Schluth says it’s obvious that this should be back in the spotlight.
The other new items on the list — numbers three and eight — relate to pediatric patients, and emphasize the notion that you can’t just treat children as small adults, he says. Their growing bodies require special care and consideration, and if your facility isn’t a pediatric one and you have pediatric patients, you should pay special attention to those issues. Consult with specialists on those areas to make sure you are treating children like children.
The order of the list is based on ECRI’s "internal judgment," he says. It won’t apply to every facility, but Schluth says it can be a starting point for discussion. There are others that didn’t make the list that might be more important for your facility. There is a self-assessment tool online for each of the 10 topics that you can send out to departments. It has 10 to 15 questions that will show the risk of each of these for your facility, whether one is particularly high or not, and that can be a starting point.
While those tools are generally for members of ECRI only, Schluth says anyone can call and see if "we can work something out."
If you aren’t a member and don’t want to make that call, look at whether you had events in these areas; ask staff in the relevant departments where they think the gaps in safety are, what worries them. "I think that people in most hospitals will find most of these items resonate," he says.
For more information on this topic, contact Rob Schluth, Senior Project Officer, ECRI Institute, Plymouth Meeting, PA. Telephone: (610) 825-6000.