Alarm hazards again top ECRI's list of 10 health IT troubles

November 07, 2012
by Brendon Nafziger, DOTmed News Associate Editor
The danger of health care providers ignoring patient alarms again topped ECRI's annual report of the 10 most urgent hazards in health IT, closely followed by the sometimes deadly failures of drug pumps and risks from medical devices that emit ionizing radiation.

If this feels like déjà vu, it's because it sort of is: alarm management, infusion pumps and CT scanner errors also topped ECRI Institute's 2011 list.

The current list, the Top 10 Health Technology Hazards list for 2013, is the sixth published by ECRI, a nonprofit that works in health care safety and technology.

There were new entrants this year, of course, including the very 21st century problem of doctors getting distracted by smartphones and other mobile devices. And while there are sure to be new entries in the 2014 list too, ECRI says you shouldn't be surprised if alarm hazards pop up again.

"The potential for alarm-related incidents leading to patient harm exists every minute of every day in virtually all health care facilities," ECRI said in the report. "In truth, alarm issues may always warrant inclusion on a list of the most-pressing health technology hazards, as alarms are ubiquitous and the risks cannot fully be eliminated."

An alarming hazard

Because of the profusion of patient monitors and other devices that produce electronic beeps when the patient has a problem or when the device does (such as a low battery), nurses and other providers can suffer from "alarm fatigue" — desensitization to the potentially critical noises coming from the machines surrounding them. Sometimes, the provider could even turn down the volume of the alarm or modify its settings so its alarm-giving threshold is out of a safe range.

As a result, providers can miss urgent alerts and patients can be put in jeopardy.

It's not a new problem, as evidenced by its reappearance in this year's list. But it's a knotty one, and it has attracted the concerned attention of the industry. In October of last year, in fact, a summit looked at the issue, convened by the ECRI Institute, along with the Association for the Advancement of Medical Instrumentation, the Food and Drug Administration, the Joint Commission and the American College of Clinical Engineering.

And some providers are making progress. ECTI cited Johns Hopkins Hospital, winner of the group's 2012 Health Devices Achievement Award, for work it did to analyze alarms at units across the institution and optimize their settings.

"By making modest changes to default parameter settings, along with standardizing care and equipment and providing reliable ancillary alarm notification, the team was able to significantly reduce the number of non-actionable, clinically insignificant alarms," ECRI said.

Other returning top problems

Citing an AAMI report, ECRI said the FDA found 710 deaths linked to errors with infusion pumps, which deliver sometimes life-saving drugs to patients, from 2005 to 2009. But ECRI said many problems with infusion pumps, number two on the list, appear to be preventable. Analyzing its own data, some 500 events gathered from 2010 to 2012, ECRI said it found 75 percent could have been solved by integrating the pumps with electronic ordering and administering systems. These in turn could have checked pump programming against medication orders, ECRI said.

The dangers of medical radiation also made it back this year, at number three on the list, although ECRI expanded the entry from 2011's, which was limited to CT scanner overuse, to include all diagnostic devices that emit ionizing radiation. Interestingly, ECRI said one concern is using X-ray equipment tested for adults on children — something shared by number seven on this year's list, which was the thoughtless use of devices designed for grown-ups on the pediatric population. This problem was actually addressed by the FDA over the summer in a draft document for device manufacturers, and it's something providers should also be aware of.

"Radiation dose settings designed for adults are usually inappropriate for children," ECRI said. "The use of such settings exposes young, still-developing patients to excessive radiation-a significant concern because radiation-linked cancer risks are higher for pediatric patients."

For the full list, go here: here.