High-tech haz­ards

Alarm haz­ards tops ECRI list of health dan­gers

Modern Healthcare - - THE WEEK IN HEALTHCARE - Mau­reen Mck­in­ney

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.”

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