Health technology hazards
The Emergency Care Research Institute (ECRI) has provided a list of the top 10 health technology hazards for 2016. Not all of them are directly applicable to us. We will focus on those items which are applicable, but we will spend some time describing the methods used in creating the list. ECRI uses experts and patient safety analysts to nominate topics based on investigating incidents, testing medical devices, observing operations and assessing practices, reviewing the literature, and engaging in discussions with everybody involved. Think of the discussion part as similar to crew resource management. People who use, make, maintain, sell, and buy the technology are involved. What factors are discussed?
Severity tops the list. An estimate is made of how likely serious injury or death will occur. How frequently does the hazard occur? When the hazard occurs how likely is it to spread? We need to expand our thinking of technology hazards beyond simple, one time equipment failure. Is the problem insidious? In other words, is the problem difficult to recognize and can is cause other problems downstream. Another, perhaps surprising, consideration is the profile. Will public recognition of the event create a negative perception of your organization? The final item is prevention. What can be done to remove or minimize the risk? In some cases, raising awareness of the hazard is a major step in reducing the potential for harm. What are some of the technology hazards we should address?
Missed alarms can result in patient injury or fatality. We must be prepared to respond to actionable clinical alarms in a timely manner. It should be remembered that the presence of an alarm on a device does not relieve our responsibility for ongoing clinical monitoring. Alarm conditions might not be detected by physiologic monitors, ventilators, or infusion pumps. When alarms are activated, staff must notice it, determine if the alarm requires a response, and respond to it correctly. Alarms that sound in error frequently may lead clinicians to not give them adequate attention.
As we become more reliant on electronic health information technology (HIT) systems, we must ensure that they are compatible with our workflow. Issues such as: missed information, mistaken application of values (dosing, time, and standing order/protocol use), input errors, and workarounds (shortcuts) can result in delayed, missed, or incorrect therapies.
Unsafe injection practices are still occurring too frequently, resulting in transmission of blood-borne viruses, bacteria, and other pathogens. Risky practices include: reusing needles and/or syringes, sharing insulin pen among multiple people (even with a new needle), using a single-dose medication via for multiple people, and failing to use proper aseptic technique. In addition to making our patients sicker or killing them, we can damage the reputation of our profession and service. Healthcare providers guilty of such egregious behavior have faced criminal penalties and imprisonment.
Plugging unauthorized devices or accessories into the USB port of a medical device may cause it to malfunction. When this is done the device may shut down, change its setting, cease to monitor the patient, or fail to accurately alarm.
Remember these hazards were included as part of selective, not an all-inclusive, list. Use the methods described in the first two paragraphs to search for hazards. Do not limit your search to technological issues. These methods can create an organizational situational awareness of risk. Constant scene size up is not limited to scenes.
“Health Devices 2015” Emergency Care Research Institute, November, 2015.
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