Patient Safety Congress Focuses on Technology Hazards

Posted May 13, 2012

When the staff at Nancy Pratt’s facility studied patient data from its electronic medical record (EMR) systems, they discovered some eye-popping misinformation.

“We found large groups of patients who were babies, less than 1 year old, and obese and smoking,” said Pratt, RN, senior vice president of clinical effectiveness at Sharp HealthCare in San Diego, CA.

It turned out the EMR system had poor processes for identifying and managing data errors, resulting in records with wildly incorrect information. Pratt and other speakers detailed the risks that come with the use of some cutting-edge healthcare technologies at the National Patient Safety Congress, which was held May 23-25 near Washington, D.C. and sponsored by the National Patient Safety Foundation.

Beyond issues with EMR systems, Pratt also spoke about the dangers of tubing misconnections.

“It’s 2012. Don’t you think we shouldn’t be able to plug an enteral feeding tube into an intravenous (IV) tube?” she asked. “That is just ridiculous. No other high reliability industry would tolerate those kinds of risks in the workplace. It is just a design flaw.”

Pratt said that standards are being developed now to help manufacturers design better connectors, but they won’t be implemented by device makers until 2014. A joint international working group is developing small bore connector standards. An AAMI working group develops positions on the drafts and considers adoption of the standards.

The first in a group of six standards—80369-1—was published in 2011, and provides the general requirements for small bore connectors for liquids and gases. The remaining standards in the series will focus on designs for a specific clinical application such as a breathing system connector that can’t hook up to an IV tube.

Leah Lough, executive vice president of the AAMI Foundation, spoke in a separate session about how the foundation’s Healthcare Technology Safety Institute (HTSI) can help combat technology hazards. The institute recently received $328,660 from the CareFusion Foundation to fund an infusion pump research project, and plans to pursue other projects focusing on “issues and challenges surrounding devices that can’t be addressed by a standard or a regulation,” she said.

Pratt is a member of the AAMI Foundation’s National Council for Healthcare Technology Safety, which oversees HTSI’s activities.

Turning to another issue that has a significant impact on patient safety, Lough said the institute has started work on alarms management, an issue that has received national media attention over the past couple of years.

Part of the problem is “alarm fatigue,” wherein nurses and clinicians are bombarded by numerous alarms, sometimes up to 350 a day, Lough said. Clinicians may grow immune to truly life-threatening events because such alerts are “lost in all the noise of alarms,” she said.

AAMI, the U.S. Food and Drug Administration (FDA), and other stakeholder groups held a summit last year to determine the 13 priorities for improving alarms management.

For more information on HTSI, which is also undertaking projects to improve infusion safety, click here.