AAMI News November 2016

Foundation Forum Probes Intersection of Technology, Safety

Too many otherwise healthy patients are dying in hospitals when changes in technology, procedures, and culture could save them. That was the major theme illustrated by several case studies of heartbreaking, preventable patient deaths presented during the AAMI Foundation’s regional meeting in Chicago, IL, Sept. 27–28.

Sue Carol Verrillo
Sue Carol Verrillo explains how real-time monitoring technology empowered nurses and saved lives at The Johns Hopkins Hospital in Baltimore, MD.

At the meeting, 124 physicians, nurses, patient safety advocates, and others from more than 18 leading healthcare delivery organizations discussed some of the most critical and challenging issues faced in healthcare—infusion therapy safety, alarm management, and continuous monitoring of patients on opioids.

“Bad stuff happens to people in hospitals; we all understand that. What should bother us is that bad stuff happens to non-sick patients in our hospitals,” said keynote speaker Frank J. Overdyk, MSEE, MD, a staff anesthesiologist at Roper St. Francis Health System in Charleston, SC, and a member of the AAMI Foundation’s Board of Directors. “This is where people go—they trust their doctors, they trust their medical facilities that they go to for care.”

In one “failure to rescue” case described by Overdyk, a 39-year-old mother admitted to the hospital for kidney stones died of a brain injury while on a morphine drip. With better education for clinicians and continuous monitoring of patients, she and several others like her would not have died, he said.

Medical errors are the third leading cause of death in the United States, according to a 2016 study published in the journal BMJ. Technology-related issues, such as IV medication errors and alarm fatigue, contribute to many of these deaths. But many of the stakeholders at the meeting offered hope through a combination of cutting-edge technology and common-sense procedures.

Speakers discussed their experiences with systems to centralize and manage the monitoring of pulse oximetry, ventilators, and IV infusions, as well as with managing the alarms produced by these technologies. Tina M. Suess, MHA, BSN, manager of medication safety integration at Lancaster General Health in Lancaster, PA, detailed a smart pump system that directly integrates with electronic health records. That means nurses no longer have to search through drug libraries to program an IV infusion—and possibly make a mistake while doing so.

“We believe the path we’re creating will be the one you’re following,” Suess said.

Sue Carol Verrillo, RN, MSN, nurse manager at The Johns Hopkins Hospital in Baltimore, MD, described a three-month pilot study to monitor patient vital signs after surgery—and the alarms those vitals generate—that was directly responsible for preventing the deaths of six patients. Once the technology and vigilance were in place, clinicians found evidence of undiagnosed medical conditions and were able to intervene before it was too late.

“Patients want to feel safe in the hospital. They don’t feel safe. When they come in and we said we’ll watch their vital signs all night and day—they loved it,” Verrillo said. “You have knowledge because you have data. It made a big difference and empowered the nurses with that knowledge ... then you make your decisions as a team.”

Since 2014, the AAMI Foundation has established four patient safety initiatives: the National Coalition for Infusion Therapy Safety, the National Coalition to Promote Continuous Monitoring of Patients on Opioids, the National Coalition for Alarm Management Safety, and the Home Health Infusion Initiative. For more information and free resources, please visit www.aami.org/foundation.

 Case Studies and White Papers

The Safety Innovation series of papers offer practical guidance from leading health organizations. They are available for download at www.aami.org/safetyinnovation.