Alarms Return to Top Spot in ECRI Annual Hazards List


Posted December 3, 2014

A familiar face tops ECRI Institute’s list of technology hazards that healthcare providers should watch for in 2015.

2015 Top 10 ChallengesLacking adequate alarm configuration policies and practice leads the list, beating out having incorrect or missing data in electronic health records and other healthcare information technology systems.

In the report, ECRI notes that strategies for reducing alarm hazards typically address alarm fatigue only. However, healthcare facilities need to broaden their strategies to improve the management of clinical alarm systems to include examining configuration policies and practices. Doing so should be a top priority, given The Joint Commission’s National Patient Safety Goal (NPSG) on alarm safety.

“Inappropriate alarm configurations practices—that is the selection of values or settings that are inappropriate for the circumstances of the patient’s care—could lead to (1) caregivers not being notified when a valid alarm condition develops, or (2) caregivers being exposed to an excessive number of alarms, specifically ones that sound for clinically insignificant conditions (e.g., those that don’t require a staff response).”

Alarm volume settings also present a unique set of challenges. “Alarms could be missed if the alarm volume is set to an inaudible level or if the sound of the alarm is disabled, indefinitely silenced, or otherwise obscured, preventing staff from hearing the alarm when it activates,” according to the report.

To combat this hazard, ECRI makes several recommendations, including having appropriate default parameter alarm settings and volumes and training  clinical staff about alarm configuration practice guidelines.

The AAMI Foundation’s Healthcare Technology Safety Institute has a number of resources dedicated to alarm safety. Earlier this year, HTSI convened a meeting of stakeholders to address alarm management. This coalition has met monthly to discuss best practice and will create a compendium of current parameter settings and reasons for settings.

Newcomer to the List

Managing recalls made its debut on the list, indicating a need for healthcare facilities to update their systems and protocols for handling these events. As the U.S. Food and Drug Administration noted in a 2014 report, the annual number of medical device recalls almost doubled between fiscal year (FY) 2003 and FY 2012, from 604 to 1,190. “Increased effort—or a more robust system—will be required in order to verify that any affected devices have been identified and that the specified remediating steps have been taken,” according to the ECRI report. The cover story in the most current issue of BI&T (Biomedical Instrumentation & Technology) is devoted to the topic of medical device recalls.

ECRI recommends that healthcare facilities’ management take a proactive role in ensuring collaboration among those departments that deal with recalled devices; designate recall and safety alert management as a critical patient safety activity; confirm that alerts have been received by the appropriate party; and a have a written policy in place indicating to whom alerts should be sent.

AAMI released its own list of the top medical device challenges this past fall. In that list, which is based on responses to a survey sent to healthcare technology management (HTM) professionals, the No. 1 challenge was managing devices and systems on the IT network.

The full ECRI 2015 list is as follows:

    1. Alarm hazards: Inadequate alarm configuration policies and practices
    2. Data integrity: Incorrect or missing data in electronic health records and other health IT systems
    3. Mix-up of IV lines leading to misadministration of drugs and solutions
    4. Inadequate reprocessing of endoscopes and surgical instruments
    5. Ventilator disconnections not caught because of mis-set or missed alarms
    6. Patient-handling device use errors and device failures
    7. “Dose creep”: Unnoticed variations in diagnostic radiation exposures
    8. Robotic surgery: Complications due to insufficient training
    9. Cybersecurity: Insufficient protections for medical devices and systems
    10. Overwhelmed recall and safety alert management programs