Alarm hazards tops ECRI list of health dangers
Hospitals are enthusiastic users of cutting-edge medical technology, but every device, from beeping alarms to CT scanners, brings safety risks, according to the ECRI Institute. And in its newly released list of Top 10 Health Technology Hazards for 2012, the Plymouth Meeting, Pa.-based not-for-profit research organization says it’s providing hospitals with a jumping-off point for their own improvement efforts. “We see this list as a tool for healthcare organizations to use to prioritize their own medical technology safety initiatives,” said James Keller, the ECRI Institute’s vice president of health technology evaluation and safety.
Now in its fifth iteration, the yearly list is compiled using a number of sources, including incident reports submitted by hospitals. The organization ranks items based on a hazard’s degree of potential harm, the likelihood that it will occur, how widespread the incident would be, and whether or not it would be a high-profile event.
Surgical fires, for instance, which appear on the seventh spot on this year’s list—up from ninth place last year—are rare occurrences, Keller said. But when they do occur, they can cause serious harm and are almost always a high-profile event for a hospital, Keller said. “Hospitals have a much greater awareness of the risk of surgical fires now, but because they can be tricky to prevent, we still think it’s important to keep them on our list,” he added.
After two surgical fires occurred within an eight-month period in 2003 at Christiana Care Health System, the two-hospital system based in Wilmington, Del., rolled out a prevention strategy that leaders hoped would not lose momentum as time went on.
“There was a lack of appreciation on the part of the staff about the risk of fire,” said Dr. Kenneth Silverstein, chairman of Christiana Care’s anesthesiology department, who spoke without knowledge of the yet-to-be-published report. “What we saw is that people were very aware of what needed to be done during training, but the next day and the next week, that awareness would wane. Our challenge was to keep that awareness day after day, for every procedure.”
The solution, Silverstein said, was a quick, three-tiered risk assessment performed for each surgical procedure that determined whether there was a heat source and open oxygen, and whether the two were being used in close proximity to one another. Each risk level has its own specific set of prevention protocols.
That fire prevention step is now embedded in the health system’s existing universal protocol, which precedes each surgery. “It’s on the checklist now, and we’ve capitalized on a process that already exists,” said Silverstein, who recently teamed up with the U.S. Food and Drug Administration on a surgical fire prevention initiative.
In addition to surgical fires, several other hazards appeared on this year’s and last year’s lists. Cross-contamination from flexible endoscopes—last year’s No. 3 hazard—held the fourth spot on this year’s list. Needlesticks held the eighth spot on both lists. A few new hazards appeared on this year’s list, too, including anesthesia hazards from incomplete pre-use inspection, and poor usability of home-health devices.
Home-health devices made the list because of a growing trend in care being provided outside the hospital, Keller said.
Another new hazard addresses medication errors using infusion pumps, which appears in the third spot on the list. Although smart infusion pumps have built-in alerts, they also have a high degree of complexity, Keller said.
“Smart pumps have the ability to prevent medication errors, but organizations must have the resources available to monitor overrides so that enhancements can be made,” said Carly Feldott, medication safety program director at 815-bed Vanderbilt University Medical Center, Nashville. “Some of the safety set-ups can be bypassed and there is still the potential for error.” Like Silverstein, Feldott had not seen the ECRI report when she was interviewed.
Topping the ECRI Institute’s list this year is alarm hazards, a term that encompasses several different alarm-related issues, including alarm fatigue—when staff members become desensitized to incessantly beeping alarms on monitoring equipment—and alarms that are not relayed to appropriate staff members.
“Alarm-based devices are ubiquitous in hospitals and there is tremendous growth in areas of care that did not use them before,” Keller said. Alarms play a role in a large number of serious incidents, many of which go unreported, he said, citing an analysis of five years of problemreporting databases by the ECRI Institute, which found more than 200 alarm-related deaths.
To help to mitigate that risk, as well as the risk of the other incidents on the list, the ECRI Institute has created 10 self-assessment surveys, tailored for each hazard, which allow hospitals to review their organizations’ medical technology safety.
“There are a lot of things hospitals can do to reduce their risk, “Keller said. “Hopefully, alarm hazards won’t be at the top of the list for much longer.”