By Gerry Castro, PhD, project director, Patient Safety Initiatives
Happy New Year!
Technology will continue to be at the forefront of any discussion on patient safety in the new decade. The Joint Commission, along with other prominent organizations in the National Patient Safety Collaborative, recommends the Top 10 Health Technology Hazards for 2020 developed by ECRI Institute.
This list was compiled thoughtfully, with topics nominated based upon:
- incident investigations
- medical device testing
- literature review
- field observation
- stakeholder feedback
While these issues vary by setting, each represents a need for greater awareness.
The Top 10 Health Technology Hazards for 2020 are:
1) Misuse of Surgical Staplers. A June 2019 focus and analysis by the Food and Drug Administration (FDA) detailed problems associated with the use of surgical staplers renewed interest in this topic. Relative to the number of procedures, the reported adverse event rate is low, but problems with stapler use can lead to:
- tissue damage
Although staplers usually function as intended, ECRI notes problems associated with:
- selecting incorrect staple size
- clamping on tissue that is too thick or thin
- clamping on, or firing over, another instrument or clip
2) Adoption of Point-of-Care Ultrasound Is Outpacing Safeguards. The increased use of ultrasounds by clinicians at the bedside and surgical robotic procedures (hazard #5) with limited evidence are two issues highlighted in the report that require careful oversight as this trend continues. Risks associated with ultrasound use at the bedside include:
- inappropriate use
overreliance on the technology when a more comprehensive exam is indicated
3) Infection Risks from Sterile Processing Errors in Medical and Dental Offices. With the trend toward providing more care outside of the hospital setting, it is unsurprising that more medical technology and associated hazards follow. In general, the hospital is a more controlled environment with more infrastructure and experts to handle problems. ECRI reports that numerous oversights and improper sterilization processes have been observed in outpatient settings, but the greatest risk is the potential for widespread patient safety risk that is difficult to detect. If medical/dental offices are using their own improperly sterilized equipment, the risk is not only widespread but difficult to detect. Patients, after all, don’t know the equipment wasn’t properly sterilized. When symptoms appear, which can be deadly for older or immunocompromised patients, there would be no way for them to connect their illness with the improperly sterilized equipment in the medical/dental offices. By contrast, hospital staff are trained to constantly monitor for infection risk.
4) Hemodialysis Risks with Central Venous Catheters—Will the Home Dialysis Push Increase the Dangers? Patients receive increasingly complex treatment and use more medical technology at home. ECRI highlights the convergence of these trends with risks associated with treatment of kidney disease at home and those patients receiving treatment through a central venous catheter beyond the recommended duration.
5) Unproven Surgical Robotic Procedures May Put Patients at Risk. Use of surgical robotic procedures can be subject to similar risks as those for ultrasound (hazard #2) such as:
- inappropriate use
- overreliance on the technology
ECRI reiterates the recommendation in the FDA Safety Communication released earlier this year to review the need for caution in using robotically assisted surgical devices in women’s health.
6) Alarm, Alert and Notification Overload. Alarm, alert and notification overload focuses on the cumulative cognitive load of all the notifications that clinicians experience and how it affects their work. The global notification burden should be considered as a factor that can affect work, along with time pressures and competing administrative or clinical tasks. While improving clinical alarm system safety is a Joint Commission National Patient Safety Goal, universal solutions have yet to be identified to provide a systematic and coordinated approach to alarm management.
7) Cybersecurity Risks in the Connected Home Health Care Environment. Medical devices used in the home environment can pose challenges because of:
- limited physical access
- reliance on patients’ home networks for device updates
- potential cybersecurity risks
These issues are compounded by users who may have difficulty operating newer technology.
8) Missing Implant Data Can Delay or Add Danger to MRI Scans. When health information technology, including electronic health records (EHRs), works well it can store and provide access to relevant clinical information when needed. However, ECRI identifies challenges with locating information about patient implants and intended medication dose administration time (hazard #9).
Patients’ medical implant information is often scattered throughout various information systems and may not be accessible or available to the relevant clinicians in a timely manner.
9) Medication Errors from Dose Timing Discrepancies in EHRs. Medications can be administered at a time later than intended because clinicians may be unaware of a default administration time in the computerized provider order entry (CPOE) system.
10) Loose Nuts and Bolts Can Lead to Catastrophic Device Failures and Severe Injury. Regular device maintenance, updates and upkeep is a basic expectation for any organization. Loose nuts, bolts, screws or fasteners are not commonly included in maintenance. ECRI warns that over the past two years, it has received almost two dozen report of loose fasteners on medical devices. Devices with loose fasteners can cause catastrophic harm to patients by:
While the list highlights risks associated with specific technologies and settings, it’s our hope that it also illustrates the need of being mindful of emerging risks associated with broader trends in health care.
Gerard M. Castro, PhD, MPH is project director for Patient Safety Initiatives in the Office of Quality and Patient Safety at The Joint Commission. In this role, he has primary responsibility for The Joint Commission sentinel event database, and manages the coordination, reporting and tracking of sentinel and safety events, in addition to other patient-safety initiatives in the Division of Healthcare Improvement.