Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

November 2018

· ECRI’s Top 10 Health Technology Hazards for 2019

· Privacy Curtains, Shared Rooms, and HAI’s

· More on Hearing Loss

· OMG! Not My iPhone!

ECRI’s Top 10 Health Technology Hazards for 2019

ECRI Institute has released its Top 10 list for Health Technology Hazards for 2019 (ECRI 2018). Number 1 on the list is the threat of hackers and cybersecurity attacks.

Not surprisingly, two of the Top 10 items pertain to alarm issues. One deals with cases of brain damage or death due to ventilator breathing circuit disconnections during which no alarm activated because alarms were not set appropriately. The other deals with alarm customization that can create opportunities for missed alarms, and thus patient harm, when not handled properly. See our list of our prior columns on alarm-related issues below.

Some old “staples”, such as retained surgical sponges and problems with contaminated endoscopes, remain on the List.

We’re pleased to see that flawed battery charging systems and practices made the list. That was the topic of our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”. In that column we provided many examples of battery-related problems that caused patient harm. We stressed that every hospital should have an organized centralized program for battery maintenance and do a full inventory of all your systems that utilize batteries. The sorts of questions you should be asking are:

What items use batteries?
What would be the patient (or facility) risk if the battery failed?
What type of battery does this equipment use?
How do you know how much battery life is left?
Is there a way the battery warns when charge is low?
Is it audible? Is it visible?
Who checks the status of the battery?
How often do they check the status?
Are there recommended replacement times?
Is the battery rechargeable?
If so, is there a memory? (could the battery life diminish with frequent charging?)
How are various devices recharged on the units where they are used?
Is the correct charger used with this battery? (use of the wrong charger can result in undercharging)
If the device this battery is in loses all power does it reset to prior settings or to default settings when power is restored?
Who keeps track of all our battery-related issues?
Are there battery-related issues in any of our root cause analyses (RCA’s) or incident investigations?
How is our staff educated on use of this device and battery issues?
Do we survey end-users or check service log issues before we reorder batteries for this device?
Does your “Ticket to Ride” patient transport communication tool have an item for discussion of battery life issues on any transported devices?
Do you include looking at battery charging/recharging issues when you do your Patient Safety Walk Rounds?

And if you are using cell phones or pagers for alerting staff to various alarms, consider doing a FMEA (failure mode and effects analysis) and ask not only what would happen if the primary responder’s battery is low but also what would happen if more than one responder’s battery is low.

We also note that battery issues are one of the items you might pay attention to when doing Patient Safety Walk Rounds (see our February 27, 2018 Patient Safety Tip of the Week “Update on Patient Safety Walk Rounds”).

The full ECRI Top 10 List for 2019:

1. Hackers Can Exploit Remote Access to Systems, Disrupting Healthcare Operations

2. “Clean” Mattresses Can Ooze Body Fluids onto Patients

3. Retained Sponges Persist as a Surgical Complication Despite Manual Counts

4. Improperly Set Ventilator Alarms Put Patients at Risk for Hypoxic Brain Injury or Death

5. Mishandling Flexible Endoscopes after Disinfection Can Lead to Patient Infections

6. Confusing Dose Rate with Flow Rate Can Lead to Infusion Pump Medication Errors

7. Improper Customization of Physiologic Monitor Alarm Settings May Result in Missed Alarms

8. Injury Risk from Overhead Patient Lift Systems

9. Cleaning Fluid Seeping into Electrical Components Can Lead to Equipment Damage and Fires

10. Flawed Battery Charging Systems and Practices Can Affect Device Operation

We hope you’ll go to the ECRI site to read all their comments and recommendations on each of the items in their Top 10 List.

Prior Patient Safety Tips of the Week pertaining to alarm-related issues:

March 5, 2007 “Disabled Alarms”
March 26, 2007 “Alarms Should Point to the Problem”
April 2, 2007 “More Alarm Issues”
June 19, 2007 “Unintended Consequences of Technological Solutons”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue”
March 16, 2010 “A Patient Safety Scavenger Hunt”
November 2010 “Alarms in the Operating Room”
February 22, 2011 “Rethinking Alarms”
February 2013 “Joint Commission Proposes New 2014 National Patient Safety Goal”
May 2013 “Joint Commission Sentinel Event Alert: Alarm Safety”
July 2, 2013 “Issues in Alarm Management”
August 2013 “Joint Commission Formalizes 2014 NPSG on Alarm Management”
February 4, 2014 “But What If the Battery Runs Low?”
October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”
December 15, 2015 “Vital Sign Monitoring at Night”
February 9, 2016 “It was just a matter of time…”
August 16, 2016 “How Is Your Alarm Management Initiative Going?”
February 21, 2017 “Alarm Fatigue in the ED”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
April 25, 2017 “Dialysis and Alarm Fatigue”
October 17, 2017 “Progress on Alarm Management”
November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
May 1 2018 “Refrigerator Alarms”

References:

ECRI Institute. 2019 Top 10 Health Technology Hazards. ECRI 2018

https://www.ecri.org/Pages/Top-Ten-Tech-Hazards.aspx

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Privacy Curtains, Shared Rooms, and HAI’s

A disturbing finding in a recent study will make hospitals rethink some of their laundering/cleaning practices. Shek et al. (Shek 2018) assessed microbial burdens on hospital privacy curtains. They found that such curtains, minimally contaminated when first hung, tested positive for MRSA by day 14, and by day21 had MRSA loads that exceeded dangerous levels. The curtains were not in rooms occupied by patients with MRSA. The findings indicate that regular curtain contact that occurs in proximity to an occupied patient bed results in increasing colonization over time. Given that they sampled areas where people hold curtains, the researchers felt it likely that the increasing contamination was because of direct contact. The results suggest that curtains are a source of cross-contamination in hospitals. Because between days 10 and 14 after being hung curtains showed increased MRSA positivity, the authors suggest this may represent an opportune time to intervene, either by cleaning or replacing the curtains.

One might speculate lesser contact with privacy curtains might explain why studies have shown lower rates of some hospital-acquired infections in patients housed in private rooms. Analyzing over a million discharge records in Texas, O’Neill et al. (O’Neill 2018) found that patients who stayed in bay rooms had 64 percent more central line infections than patients who stayed in private rooms. Even after adjusting for relevant covariates, patients assigned to bay rooms had a 21 percent greater relative risk of a central line infection, compared with patients assigned to private rooms. At the hospital level, a 10% increase in private rooms was associated with an 8.6% decrease in central line infections, regardless of individual patients' room assignment.

And a study done in NICU’s (Washam 2018) showed that infants housed in a single-bed unit were associated with a significantly decreased risk of both MRSA and MSSA acquisition compared with infants housed in multibed pods.

That prestigious medical journal, Reader’s Digest, picked up on the Shek study on hospital privacy curtains and extended it to the “10 Things to Never Touch in Hospitals” (Gold 2018). Actually, that article provides links to the medical journals containing the original studies documenting the risks. The 10 items are:

Privacy curtains
Bed rails
Tables placed over patient beds
IV poles
Elevator buttons
Visitor chair armrests
Telephones
Water faucets
Door handles
Objects nurses use often

And, of course, items often used by nurses and other healthcare professionals are mobile handheld devices (MHD’s) - tablets and smartphones- that are used to facilitate care documentation and as resource tools. A study at Mary Washington Health care in Fredericksburg,Virginia, sponsored by the Nursing Research Council (NRC), assessed the infection potential of MHDs and possible cleaning methods (Wentz 2018). They found that the mean MHD bioburden before cleaning was 106.8 relative light units (RLUs), indicating bacterial contamination. The mean post-cleaning bioburden was 49.98 RLUs, within the “clean” range. The results indicate that this regimen (70% isopropyl alcohol and 15 seconds of friction) effectively cleans MHDs and decreases the risk of spreading harmful bacteria to patients in the healthcare setting.

Bottom line: cross-contamination occurs frequently wherever healthcare workers come in contact with surfaces or equipment or other objects. Appropriate environmental cleaning at the right time should play a key role in our efforts to reduce hospital-acquired infections.

References:

Shek K, Patidar R, Kohja Z, et al, Rate of contamination of hospital privacy curtains in a burns/plastic war021d: A longitudinal study, American Journal of Infection Control 2018; 46(9): 1019-1021

https://www.ajicjournal.org/article/S0196-6553(18)30155-X/pdf

O’Neill L, Park S-H, Rosinia F. The role of the built environment and private rooms for reducing central line-associated bloodstream infections. PLOS One 2018; Published: July 27, 2018

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201002

Washam MC, Ankrum A, Haberman BE, et al. Risk Factors for Staphylococcus aureus Acquisition in the Neonatal Intensive Care Unit: A Matched Case-Case-Control Study. Infection Control Hospital Epidemiology 2018; 39(1): 46-52

https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/risk-factors-for-staphylococcus-aureus-acquisition-in-the-neonatal-intensive-care-unit-a-matched-casecasecontrol-study/E0D7DF18C937F37A4E42978BB50F6DA1

Gold SS. 10 Things to Never Touch in Hospitals. Reader’s Digest 2018;

https://www.rd.com/health/wellness/things-to-never-touch-in-hospitals/

Wentz B, Bowles MJ. Mobile Devices and Healthcare-Associated Infections. Am Nurs Today 2018; 13(9)

https://www.americannursetoday.com/mobile-devices-healthcare-associated-infections/

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More on Hearing Loss

A recent story in Oncology Nursing Times (Schulmeister 2018) illustrates one of the hazards of hearing impairment. A cancer patient arrived at busy outpatient registration area. The registration clerk copied his name from his driver’s license to a computer search screen and chose the first name from result list and printed a wristband for the patient. The clerk asked the patient if the information was correct and he nodded “yes” (he was not wearing his glasses). He was then sent to a busy infusion center for his second chemotherapy treatment. There, the nurse asked him if his name is John Doe and if his birthday is the date that she read from his wristband. He nodded yes. He didn’t notice she gave wrong birthday because she had a “heavy accent” and “rattled off numbers” and the infusion room was loud and busy and that he “didn’t hear well.” He received the chemotherapy intended for another patient who had the same name but a different birthdate. There was no apparent harm but a lawsuit ensued anyway.

Obviously, there was a cascade of errors and incorrect practices that contributed to this incident. But we include it here because it does point out yet another problem that the hearing impaired are vulnerable to: patient misidentification. This, by the way, is one of scenarios in which biometrics might have helped considerably in avoiding misidentification.

In our July 2018 What's New in the Patient Safety World column “Hearing Loss and Patient Safety” we noted a study (Lin 2018) that found work- and leisure-related injuries were more prevalent among those with self-perceived hearing difficulty and another study (Simpson 2018) that showed more than 20% higher total healthcare payments among hearing impaired individuals.

Since then, another study has revealed yet another likely vulnerability. Chang et al. (Chang 2018) looked at a representative national sample of patients discharged from hospitals and found that those who reported trouble communicating with their physicians had had 32% greater odds of hospital readmission within 30 days. Their results show we need to raise awareness about the high prevalence of hearing loss among older people and educate staff on how to talk to people with hearing difficulty.

In our July 2018 What's New in the Patient Safety World column “Hearing Loss and Patient Safety” we noted a study (Mahmoudi 2018) which showed the use of hearing aids was associated with reduced probability of any ED visits and any hospitalizations and in reducing the number of nights in the hospital.

In an editorial accompanying the Mahmoudi study, Wallhagen (Wallhagen 2018) points out that hearing assessment can be simple and not time consuming. You can use a combination of a simple question and a brief objective test like a finger rub or whisper test, or a brief questionnaire like the Hearing Handicap Inventory for the Elderly. She points out that this takes minimal time and can be scheduled at regular intervals, much like the foot examination for a patient with diabetes.

But, never assume what is heard is actually understood. That emphasizes the concepts of “hear back” and “teach back” which we have stressed in our columns on health literacy and numeracy. (“Hear back” is obviously also critical in communication between healthcare professionals).

It’s time we recognize the high prevalence of hearing impairment and identify it early so that we can ensure we communicate with our patients in a meaningful way that will help avoid some of the unwanted consequences noted above.

Some of our columns on the impact of hearing loss:

September 12, 2017 “Can You Hear Me Now?”
February 2018 “Global Sensory Impairment and Patient Safety”
July 2018 “Hearing Loss and Patient Safety”

References:

Schulmeister L. Cancer Treatment to the Wrong Patient: Why Does This Still Happen? Oncology Nursing News 2018; March 8, 2018

http://www.oncnursingnews.com/publications/oncology-nurse/2018/march-2018/cancer-treatment-to-the-wrong-patient-why-does-this-still-happen

Lin HW, Mahboubi H, Bhattacharyya N. Self-reported Hearing Difficulty and Risk of Accidental Injury in US Adults, 2007 to 2015. JAMA Otolaryngol Head Neck Surg 2018; Published online March 22, 2018

https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2676015

Simpson AN, Simpson KN, Dubno JR. Healthcare Costs for Insured Older U.S. Adults with Hearing Loss. Journal of the American Geriatrics Society 2018; First published: 24 May 2018

https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15425

Chang JE, Weinstein B, Chodosh J, Blustein J. Hospital Readmission Risk for Patients with Self‐Reported Hearing Loss and Communication Trouble. J Am Geriatr Soc 2018; First published: 05 October 2018

https://onlinelibrary.wiley.com/doi/10.1111/jgs.15545

Mahmoudi E, Zazove P, Meade M, et al. Association Between Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss. JAMA Otolaryngol Head Neck Surg 2018; Published online April 26, 2018

https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2678187

Wallhagen MI. Hearing Aid Use and Health Care Costs Among Older Adults. JAMA Otolaryngol Head Neck Surg 2018; Published online April 26, 2018

https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2678182?redirect=true

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OMG! Not My iPhone!

There have been several recent disturbing reports of iPhones (and some other Apple devices) being wiped out by MRI units.

The story began with a blog on Reddit (u/harritaco 2018a) that said:

“One of our multi-practice facilities is having a new MRI installed and apparently something went wrong when testing the new machine. We received a call near the end of the day from the campus stating that none of their cell phones worked after testing the new MRI. My immediate thought was that the MRI must have emitted some sort of EMP, in which case we could be in a lot of trouble. We're still waiting to hear back from GE as to what happened. This facility is our DR site so my boss and the CTO were freaking out and sent one of us out there to make sure the data center was fully operational. After going out there we discovered that this issue only impacted iOS devices. iPads, iPhones, and Apple Watches were all completely disabled (or destroyed?). Every one of our assets was completely fine. It doesn't surprise me that a massive, powerful, super-conducting electromagnet is capable of doing this. What surprises me is that it is only effecting Apple products. Right now we have about 40 users impacted by this, all of which will be getting shiny new devices tonight. GE claims that the helium is what impacts the iOS devices which makes absolutely no sense to me.”

The issue only impacted iOS devices. Desktops, laptops, general healthcare equipment, and a datacenter were not affected, nor were the many Android phones in the facility at the time. And the Apple models affected were iPhone 6 and higher and Apple Watch series 0 and higher. Some of the devices eventually regained some function over time.

He initially suspected it may have been an EMP (electromagnetic pulse) generated by the MRI machine but, after the posting on Reddit, some others posted and speculated that it might be caused by the liquid helium used to cool the MRI machine. Further investigation revealed that there, indeed, had been release of helium.

He went on to do an experiment (u/harritaco 2018b) where he placed an iPhone 8+ in a sealed bag filled with some helium. After a little more than 8 minutes, the iPhone locked up. After several days it did return to a functioning state.

In an analysis of the event, Wiens (Wiens 2018) notes that the iPhone user guide says “Exposing iPhone to environments having high concentrations of industrial chemicals, including near evaporating liquified gasses such as helium, may damage or impair iPhone functionality. … If your device has been affected and shows signs of not powering on, the device can typically be recovered. Leave the unit unconnected from a charging cable and let it air out for approximately one week. The helium must fully dissipate from the device, and the device battery should fully discharge in the process. After a week, plug your device directly into a power adapter and let it charge for up to one hour. Then the device can be turned on again.” Apparently, the helium inhibits the clock/oscillator that is critical for the iPhone to function.

Since only the newer Apple products were affected, it was postulated that it could be related to Apple's recent switch from quartz components to parts called microelectromechanical system (MEMS) timing oscillators (Casey 2018a).

But the case gets more complicated. Multiple late-model Apple iPhones and Apple Watches were permanently disabled at a Delaware center after it ramped down its MRI magnet (Casey 2018b). Only newer-model Apple products such as the iPhone 8 and iPhone 10 were affected. Those with older models didn't experience any problems, nor did staff with Android phones. Unlike the prior case and though the magnet was ramped down and then back up again, there apparently was no helium release in the Delaware case. Furthermore, whereas many of the devices recovered with time in the prior case, none of the Delaware devices recovered. And, in the Delaware case it was only newer models that had wireless charging capability (hence, no iPhone 6’s) that were affected.

Though some might think the moral of the story is “don’t take your new iPhone or Apple watch near an MRI unit that is being installed or ramped down and up again”, there may also be some patient safety implications. The newer Apple watches are being touted for their ability to record EKG’s and capture bouts of arrhythmias like atrial fibrillation. Such ability could obviously become impaired if the watch fails to function. But, of even more concern, is that we might anticipate future medical equipment and devices might begin to employ microtechnologies like those mentioned above and become susceptible to the same fate as the iOS devices.

So, add this to your list of what can go wrong in the Radiology or MRI suite!

References:

u/harritaco. MRI disabled every iOS device in facility. Reddit 2018; October 8, 2018

https://www.reddit.com/r/sysadmin/comments/9mk2o7/mri_disabled_every_ios_device_in_facility/

u/harritaco. Post-mortem: MRI disables every iOS device in facility. Reddit 2018; October 29, 2018

https://www.reddit.com/r/sysadmin/comments/9si6r9/postmortem_mri_disables_every_ios_device_in/

Wiens K. iPhones are Allergic to Helium. IFIXIT.org 2018; October 30, 2018

https://ifixit.org/blog/11986/iphones-are-allergic-to-helium/

Casey B. Did MRI helium leak take out hospital's iPhones? AuntMinnie.com 2018; October 31, 2018

https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=123398

Casey B. 2nd MRI center reports problems with Apple devices. AuntMinnie.com 2018; November 1, 2018

https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=123411

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