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What’s New in the Patient Safety World
November 2019
ECRI Institute’s Top 10 Health Technology Hazards for 2020
ECRI Institute’s annual Top 10 list for Health Technology Hazards has just been published for 2020 (ECRI 2019).
Topping the list is “Misuse of Surgical Staplers”, which we discussed in our April 2019 What's New in the Patient Safety World column “FDA Warning on Surgical Staplers Opens a Can of Worms”. ECRI points out that, rather than the device itself malfunctioning, adverse consequences are most often related to how the surgical stapler is used. Errors in use include selecting an incorrect staple size, clamping on tissue that is too thick or too thin, and clamping on, or firing over, another instrument or clip. ECRI notes that effective training and familiarity should specifically include hands-on practice with the specific model of stapler to be used.
Some items on this year’s list, like $5 “Alarm, Alert, and Notification Overload” are no surprise and have been the topic of many of our columns.
But, somewhat of a surprise to us is #2 “Adoption of Point-of-Care Ultrasound Is Outpacing Safeguards”. But perhaps it shouldn’t be such a surprise. Thoughout the years, we’ve had to referee turf battles between our ED physicians and our radiologists over who can do ultrasound testing. While we’ve generally sided with the radiologists on the issue, there are clearly some circumstances where the ability to perform ultrasound on an emergent basis is desirable. One example might be confirmation of suspected cardiac tamponade. But we’ve always required strict credentialing and privileging before allowing anyone to perform bedside or point-of-care ultrasound. One of our former colleagues, Dietrich Jehle, M.D., has authored books on ultrasound in the ED (Heller 2002) and in the trauma patient (Jehle 2003).
ECRI, however, cautions that sometimes point-of-care ultrasound is used inappropriately and, at other times, is not used when it should be. It also notes that there may be overreliance on point-of-care ultrasound when a more comprehensive exam by an imaging specialist is indicated. ECRI points out that, in addition to addressing specialty-specific issues, “policies and procedures should address institution-wide concerns, including user training and credentialing, exam documentation, and data archiving”.
Number 3 on this year’s list is “Infection Risks from Sterile Processing Errors in Medical and Dental Offices”. We all know about problems related to inadequately sterilized instruments in hospitals and ASC’s (eg. contaminated endoscopes and bronchoscopes, etc.). And those have occurred in facilities that have expertise in sterilization procedures. What about those venues that lack such sophisticated expertise? ECRI notes that settings that may lack such sterilization program include medical offices (e.g., OB/GYN, dermatology), dental offices, and similar locations that are not serviced by a central sterile processing department. ECRI suggests that safety programs in such facilities should include designating a qualified staff member or contractor to support office infection prevention and control practices and providing appropriate training for, and conducting periodic competency testing of, benchtop sterilizer operators.
When we do talks on the excessive cost of healthcare in the US, we often discuss “medical arms races” and highlight the widespread adoption of surgical robots that has outpaced the evidence-based use of such devices. Hospital after hospital purchased surgical robots when their competitor down the street bought one (often with the threat their surgical or Ob/Gyn specialists would take their business to the other hospital). ECRI’s #5 on this year’s list is “Unproven Surgical Robotic Procedures May Put Patients at Risk”.
While acknowledging the utility of surgical robots in some circumstances, ECRI notes the robots may not provide tactile feedback on forces exerted on tissue and that, in some cases, complications from a robotic procedure may not appear for years. Therefore, ECRI stats that healthcare facilities “need robust processes for approving the application of surgical robots in new procedures, as well as comprehensive programs for training, credentialing, and privileging surgeons and OR staff for those procedures”. Further, ECRI cautions patients to recognize that robotic procedures are not inherently better or worse than traditional minimally invasive procedures.
Another item on the list, #8 “Missing Implant Data Can Delay or Add Danger to MRI Scans” is also one we’ve discussed in multiple columns (see the list of our prior columns below). Because some implants can heat, move, or malfunction when exposed to an MRI system’s magnetic field, they must be screened for prior to the procedure. ECRI suggests that, akin to an allergy list, organizations develop an implant list that collects all relevant information in one easy-to-access location in the electronic medical record. We like that idea!
ECRI’s #9 “Medication Errors from Dose Timing Discrepancies in EHRs” has also been the topic of many of our columns on the unintended consequences of health information technology. In our January 2013 What's New in the Patient Safety World column “More IT Unintended Consequences” we discussed the problem of default values leading to unanticipated problems. We used as an example start times for an order. We might write an order for a medication we want started now but the computer may default that order to the next “standard” time of medication administration resulting in a delay or omission of an important dose.
ECRI provides a similar example: “Late in the morning, a physician enters an order for a once-daily medication and assumes that the patient will be given the first dose that morning. At that facility, however, the default administration time programmed into the EHR for once-daily medications is 8:00 a.m. Because the order was placed later in the morning, the medication for that patient would not appear on the nurse’s worklist until the following morning, unless the prescriber was aware of the default administration time and had specifically changed the time within the order.” ECRI suggests that dose timing errors can be made less likely “if an EHR order-entry system prominently displays the scheduled medication administration time, allows prescribers to easily modify that time, and includes a “now” option for medications that need to be administered as soon as possible.” Good suggestion!
And 2 of the items on ECRI’s 2020 list, #4 “Hemodialysis Risks with Central Venous Catheters—Will the Home Dialysis Push Increase the Dangers?” and #7 “Cybersecurity Risks in the Connected Home Healthcare Environment” bring into consideration issues beyond the hospital, namely safety hazards related to care in the home.
The full ECRI 2020 list:
1. Misuse of Surgical Staplers
2. Adoption of Point-of-Care Ultrasound Is Outpacing Safeguards
3. Infection Risks from Sterile Processing Errors in Medical and Dental Offices
4. Hemodialysis Risks with Central Venous Catheters—Will the Home Dialysis Push Increase the Dangers?
5. Unproven Surgical Robotic Procedures May Put Patients at Risk
6. Alarm, Alert, and Notification Overload
7. Cybersecurity Risks in the Connected Home Healthcare Environment
8. Missing Implant Data Can Delay or Add Danger to MRI Scans
9. Medication Errors from Dose Timing Discrepancies in EHRs
10. Loose Nuts and Bolts Can Lead to Catastrophic Device Failures and Severe Injury
As usual, ECRI’s list is timely and valuable, with good recommendations. We recommend you download the free executive brief (ECRI 2019) or, if you are a member, the full document.
Some of our prior columns on patient safety issues related to MRI:
- February 19, 2008 “MRI Safety”
- March 17, 2009 “More on MRI Safety”
- October 2008 “Preventing Infection in MRI”
- March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
- January 25, 2011 “Procedural Sedation in Children”
- February 1, 2011 “MRI Safety Audit”
- October 25, 2011 “Renewed Focus on MRI Safety”
- August 2012 “Newest MRI Hazard: Ingested Magnets”
- October 22, 2013 “How Safe Is Your Radiology Suite?”
- October 21, 2014 “The Fire Department and Your Hospital”
- August 25, 2015 “Checklist for Intrahospital Transport”
- August 2016 “Guideline Update for Pediatric Sedation”
- October 2016 “MRI Safety: There’s an App for That!”
- January 17, 2017 “Pediatric MRI Safety”
- August 8, 2017 “Sedation for Pediatric MRI Rising”
- March 2018 “MRI Death a Reminder of Dangers”
- March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
- November 2018 “OMG! Not My iPhone!”
- April 2, 2019 “Unexpected Events During MRI”
- September 2019 “New MRI Hazard: Magnetic Eyelashes”
References:
ECRI Institute. 2020 Top 10 Health Technology Hazards Executive Brief. October 2019
https://www.ecri.org/landing-2020-top-ten-health-technology-hazards
Heller MB, Jehle D. Ultrasound in Emergency Medicine. Center Page, Inc.; 2nd edition (2002)
Jehle D, Heller MB. Ultrasonography in Trauma: The FAST Exam. American College of Emergency (2003)
https://www.amazon.com/Ultrasonography-Trauma-MD-Dietrich-Jehle/dp/0983428859
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