Alarm hazards, rad exposure top ECRIs top tech problems
 |
Released this month from the Plymouth Meeting, Pa.-based healthcare research organization, the list also identifies radiation exposure, medication errors and cross-contamination among the leading causes of concern.
ECRI’s top ten hazards are as follows:
1. Alarm hazards
2. Exposure hazards from radiation therapy and CT
3. Medication administration errors using infusion pumps
4. Cross-contamination from flexible endoscopes
5. Inattention to change management for medical device connectivity
6. Enteral feeding misconnections
7. Surgical fires
8. Needlesticks and other sharps injuries
9. Anesthesia hazards dues to incomplete pre-use inspection
10. Poor usability of home-use medical devices
Alarm hazards moved up one slot from last year’s list—which cited radiation overdose as 2011’s top challenge—and has gained increased awareness this year through industry efforts to reduce alarm fatigue, nuisance alarms and false alarms. The Association for the Advancement of Medical Instrumentation (AAMI) also recently held a two-day summit focusing on the problem. To address the issue, ECRI recommended organization-wide assessment, as well as close attention to individual care areas.
“Trying to fix one item in isolation may provide only a partial solution and may also introduce new opportunities for failure,” the authors wrote. “While some of our recommendations are specific to individual care areas, don’t let them keep you from looking at the bigger picture.”
Some of the recommendations include examining the alarm environment when setting up an alarm management program, establishing protocols for alarm-system settings, establishing alarm notification and response protocols, as well as creating policies to control alarm silencing, modification and disabling.
Meanwhile, radiation therapy errors can have “devastating consequences, including ineffective tumor control, as well as critical damage to normal tissue and organs that can lead to severe morbidity and death.” CT radiation in the diagnostic setting is also of concern because use is on the rise and it delivers a relatively high dose.
“One contributing factor is that image quality improves as dose levels are increased, so there is a natural tendency to use higher doses—a tendency facilitated by the lack of a legal maximum dose for CT,” the authors wrote. “Moreover, most healthcare facilities do not routinely audit CT doses, so there is a wide variation in dose for the same types of studies.”
ECRI proposed a series of 16 general and specific recommendations to address the issue, from ensuring appropriate staffing levels to recording and auditing radiation doses.
Rounding out the top three, medication administration errors using infusion pumps rose as an area in need of examination. While smart pumps have improved infusion pump technology, preventable errors do still occur, according to the organization.
ECRI recommended viewing infusion pumps as part of an overall medication delivery system, as well as considering possible integration with future medication safety systems.
Hazards are placed on the list based on four factors—degree of potential harm, likelihood of problems, commonness of precipitating factors and perceived prominence.
The full 18-page article, which details and offers recommendations for each hazard, can be found on ECRI’s website.