Safety Innovation Series
The Safety Innovation Series is a collection of white papers, reports, and guides from the Healthcare Technology Safety Institute to:
- Illuminate how leading healthcare organizations have solved a particularly tough technology-related safety issue (e.g., clinical alarm systems; infusion systems )
- Share pathways to implementing technology-based recommendations from outside experts
- Provide analytical tools for solving technology-related patient safety issues.
From planning to implementation, all papers in this Series are aimed to help healthcare organizations find innovative solutions to improve technology-related patient safety.
We encourage you to share “Safety Innovation” papers with your colleagues. They are free to download or forward to others.
If you have a technology-related case study to share, please let us know at htsi@aami.org.
Resources
Clinical Alarms
- Cardiopulmonary Monitors and Clinically Significant
Events in Critically Ill Children - Children's National Medical Center
- A team of nurses, biomedical engineers, physicians, and biostatisticians were assembled to assess the conditions associated with the generation of cardiopulmonary monitors (CPMs), including false positive alarms signals in critically ill children, and to define alternative alarm parameters that would improve CPM alarm performance. (click here)
- Note: Tables on pages 7 and 8 do not appear clearly due to the size and the complexity of the information. We are in the process of correcting this.
- Plan, Do, Check, Act: Using Action Research to Manage Alarm Systems, Signals, and Responses, The Beth Israel Deaconess Medical Center
- In the aftermath of two sentinel events in inpatient rooms at the Beth Israel Deaconess Medical Center in Boston, MA, the hospital’s leadership, and the physician, nursing, and clinical engineering staff focused comprehensively on alarmed medical devices. (click here)
- Recommendations for Alarm Signal Standardization and More Innovation,
The Christiana Care Health System Experience
- Christiana Care developed a system-wide alarm policy and protocols that defined its alarm management strategy for alarmed medical equipment, including flex monitors, standard cardiac monitors, pulse oximeters, and infusion pumps. (click here)
- Using Data to Drive Alarm
System Improvement Efforts, The Johns Hopkins Hospital Experience
- The key to reducing alarm signal noise is the collection and analysis of quantitative data to evaluate the applications of alarm system management in hospitals. (click here)
- References (click here)
Infusion Systems
- Best Practice Recommendations for Infusion Pump-Information Network Integration
- Pump integration requires pervasive and reliable wireless coverage—if pumps can’t communicate with the server via a wireless network, no integration can occur. (click here)
- Nine Recommendations To Prevent Multiple Line
Infusion Medication Errors
- From Mitigating the Risks Associated With Multiple IV Infusions. Recommendations from an interim report, Multiple Intravenous Infusions Phase 1b: Practice and Training Scan. (click here)
- Smart Pump Implementation: A Guide For Healthcare Institutions
- Institutions need to pay attention to pre- and post-smart pump implementation recommendations if they are to reap the benefits from this technology. (click here)