Common challenges, key solutions
Editor's note: This article was written by Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor, and contributing editor Matt Phillion, CSHA. Originally appeared in Briefings on Accreditation and Quality.
ECRI Institute has revealed its top 10 list of health technology hazards for 2016, and for those of us working in patient safety and quality, few if any should come as a surprise. ECRI publishes its list with the purpose of identifying possible sources of danger and minimizing the chances that an adverse event will occur. Let's take a look at the complete list and where things commonly go wrong?sometimes fatally?for our patients. (See the chart on p. 4 for a look at the hazards and possible relevant standards.)
1. Endoscope reprocessing
We've all heard the horror stories. Endoscopes (and, ECRI's report notes, duodenoscopes in particular) are notoriously hard to disinfect. The very structure of the scopes, with complex designs to allow sufficient motion to move through long, narrow channels, makes them extremely difficult to clean. Given the number of adverse events, the FDA and instrument manufacturers continue to work on a solution to the problem. Steps you can take: Emphasize with applicable staff reprocessing the risks associated with insufficient cleaning of these scopes, and what the steps are to properly clean them. The key here is to emphasize that when pre-cleaning is not done correctly, sterilization/disinfection may not be effective.
2. Missed alarms
Another situation we've seen too much of: clinical alarms. We've talked often in this space about the risks of alarm fatigue, but ECRI targets three specific cases where not recognizing or responding to an alarm puts a patient at risk:
- Was the alarm condition not detected by the device?
- Was the condition detected but not communicated to the staff?
- Was the condition not properly addressed (e.g., the staff failing to notice the alarm, or not responding correctly)?
Steps you can take: A comprehensive alarm management program is needed to address the full range of alarm hazards. This is not an activity that can be done from the top down?involve the nurses and staff who work with these alarms to get their input on methods to prevent alarm-related errors.
3. Opioid postoperative patient management
Patients who receive postoperative opioids like hydromorphone, morphine, or fentanyl are at risk, even if they're otherwise healthy, to experience drug-induced respiratory depression. ECRI recommends being on the lookout for whether the patient is on other drugs with a sedating effect; comorbidities like morbid obesity or sleep apnea; or are at risk to receive a higher dose than intended (e.g., wrong concentration, wrong medication, infusion pump programming errors).
Steps you can take: Follow recommendations from The Joint Commission and the Anesthesia Patient Safety Foundation.
4. Inadequate telemetry monitoring of patients
There are several areas where patients can be at significant risk here. For example: monitoring systems are not perfect?no system can detect all potentially lethal arrhythmias. We've also seen a rise in using telemetry monitoring for patients in areas where patients are not as closely monitored. Where the information coming in from patient monitoring devices comes into play as well?staff can miss information if they're not present to see the data as it arrives, or are busy with other tasks, which is not an uncommon issue.
Steps you can take: Make sure your staff are educated about the limitations of telemetry monitoring and that they know the risks of missed events. Look at your current patient surveillance processes and determine if and where improvements are necessary. Conduct ongoing evaluations of staffing and the acuity of care needs and adjust to meet the needs of the patient population.
5. Education and training on OR technology for clinicians
How is your OR training process? Does it provide sufficient assurance of competency? Are all relevant team members (doctors, nurses, per diems, locum tenens) included in this training? Did you know that 70% of accidents involving a medical device can be attributed to technique used or user error?
Steps you can take: Training, training, training … at hire and ongoing. Make sure staff and physicians are sufficiently trained on any new OR technologies, and make sure they know how to use the technology you've already got in place. Human error will occur, but proper education can help circumvent many errors.
6. Information technology workflow and configuration
It's a common issue?we implement something, whether it's a new device, a new process, a new computer program?but we don't take into account how this new process will impact workflow. When a new technology is hoisted upon staff members, we see many common risks, from missed information or an inability to find the information we're looking for, to not calibrating the new technology for the workspace it impacts, to input errors, desired values vs. default values, to everyone's favorite challenge: the dreaded workaround. All of these can put your patients at a higher risk for injury.
Steps you can take: Health IT selection and implementation needs to involve workflow. Will they work together well? If not, how can you adjust to make sure they do work together? Workflows can be altered to accommodate new technology, but the tech itself can be chosen and modified to enhance the workflow rather than disrupt it.
7. Injection practices
Despite all of the industry's work on infection control, we still see incidents where patients are put at risk of bloodborne viruses, bacterial infections, and more due to unsafe injection practices. We still face issues with needle reuse, sharing of insulin pens between patients, using single-dose medication between multiple patients, poor aseptic techniques when preparing medications, and more. All of these issues can lead to disease transmission between patients, damage to the organization's reputation, and even criminal prosecution.
Steps you can take: Take action. Everyone needs to be involved. Frontline staff need to engage in better practices, but leadership needs to make this a priority and give them the tools they need to improve. Even patients need to step up and be more aware of the risks. Unsafe infection practices impact everyone.
8. Mechanical failures of gamma cameras
Gamma cameras involve heavy, moving parts. ECRI's report notes that the FDA has received multiple reports of mechanical failures, including one fatal, where parts fell off, striking staff or patients. This generally occurs when the gamma cameras are not maintained properly. ECRI also found that recalls are often not handled in a timely manner, which opens the window for mechanical failures to occur.
Steps you can take: Stay current on maintenance. Follow manufacturers' guidelines regarding inspection, maintenance, and service. Remain vigilant about recalls and repairs. Don't leave patients unattended in the scan room.
9. Ventilators, intensive care unit
Although lung-protective strategies have been developed to prevent ventilator-induced lung injuries, we see a number of issues with preventing errors in this area. Existing tools and techniques are not used to their full potential, or best practices may not be adopted where needed. This is frequently the result of a knowledge deficit?either a lack of continuing education on patient ventilation, lack of understanding about ventilator functionality, or even problems with terminology used by manufacturers.
Steps you can take: Know your devices, know their uses, and be current on the most recent best practices. Assess current usage at your facility and, if needed, adopt more current, more successful practices, and evidence-based research for patient safety.
10. Medical devices and USB ports
USB ports are everywhere in technology. And while uniformity among devices has its benefits, it also increases risk, and plugging unauthorized devices into USB ports on medical devices can lead to a number of malfunctions, including unintended shutdowns, reboots, or other consequences. This can result in the patient not being monitored correctly, or not receiving medication or therapy tied to the device.
The device settings may also be compromised by USB port misuse. Calling back to number two on the ECRI list, misuse of USB ports can even result in changing alarm settings on a given device. USB port misuse can also open up devices to security breaches, leaving patient data and the healthcare facility's systems vulnerable to theft or damage.
Steps you can take: Develop, implement, and enforce a policy of USB ports on medical devices in your organization. Provide education and training at time of hire and ongoing as defined by the organization, and as applicable to staff and providers.
Note that the list produced by the ECRI Institute doesn't represent the most frequent risks or even the ones with the most severe consequences?this is a list of hazardous problems which should be prioritized and can be addressed through careful management of technologies.