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Infusion errors, instrument cleaning lead ECRI list of top tech hazards

Editor’s note: The ECRI Institute published its annual list of the top 10 health technology hazards for the industry. Readers will note that several of the top hazards in 2017 are the same as those in 2016. To guide readers through the hazards, BOAQ spoke to several experts on each issue and about steps that can be taken to prevent it. 

1.    Infusion errors
 “Number 1 on ECRI’s 2017 list of health technology hazards is IV infusion errors caused by placing too much trust in advanced pump safety features and incorrect infusion programming,” says Jean S. Clark, RHIA, CSHA, an author and speaker on accreditation and regulatory compliance. “Other causes of IV infusion errors are related to wrong volume, mixture, intravenous rate, and drug incompatibility.”

“In addition, failure to check patient identification against the arm band, order, and patient name and date of birth; and failure to check appropriate vitals such as pulse and blood pressure have caused errors. Nurse experience, training, and continuing competency requirements also have a bearing on IV infusion errors.”

Steps you can take: “Nurse education and continued competency review is key in reducing errors,” she says. “Upon hiring and at intervals established by the nursing leadership, have strict competency requirements. Competency tests and direct observation are good methods to use. Determine how much experience is required prior to hire; or, for the new nurse, direct observation with an experienced nurse for a defined period of time is a good idea. Track IV infusion errors, aggregate the data according to cause, and perform root cause analyses to determine an action plan for eliminating errors.” 

•    Food and Drug Administration (FDA), “Examples of Reported Infusion Pump Problems”
•    Association for the Advancement of Medical Instrumentation, “Majority of IV Medication Errors Linked to Clinical Practice Not Technology” 
•    PSQH, “Interoperability Preparedness: What Hospitals Can Do to Be Ready for Smart Pump-EMR Interoperability”
•    PSQH, “From Smart Pumps to Intelligent Infusion Systems – The Promise of Interoperability” 

2.    Inadequate instrument cleaning
Summary: “Inadequate cleaning of instrument is number 2 on ECRI’s list,” Clark says. “In particular, in areas where short cycle steam sterilization is used and where clean and dirty instruments pass through sterile and unsterile areas. For example, settings where eye surgery (cataract, laser, etc.) are being performed, GI labs and other areas where scopes/probes are being utilized. Inadequate training, not following manufacturer guidelines, not following heating, ventilation, and air conditioning parameters in decontamination areas, use of old instruments and delays in cleaning instruments are other factors leading to inadequate instrument cleaning.” 

Steps you can take: “Follow the Association of Perioperative Registered Nurses (AORN) guidelines for cleaning, decontaminating, and handling instruments in all procedural, surgical, and central sterile areas and follow manufacturer guidelines,” she says. “Keep information on short cycle steam sterilization rates to ensure under sterilization is not occurring. Consider the use of disposable laryngoscope blades and make sure the blades are in some type of packaging. Keep up-to-date records on surveillance of negative and positive pressure areas. Ensure competency in cleaning, decontaminating, and handling of instruments to ensure adequate cleaning.”

•    AORN, “Guideline Implementation: Surgical Instrument Cleaning”
•    AORN, “Guideline Implementation: Processing Flexible Endoscopes”
•    FDA, “Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling”

3.    Missed ventilator alarms
Summary: ECRI has discussed the risks of alarm fatigue before; where staff become overloaded or desensitized to alarms going off. New this year ECRI also notes a new problem: the difficulty in identifying where your ventilator alarm vulnerabilities lie.

Steps you can take: Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a former Joint Commission surveyor and consultant based in Trabuco Canyon, California, says that a comprehensive alarm management program is needed to address the full range of alarm hazards.

“This is not an activity that can be done from the top down,” she says. “Involve the nurses and staff who work with these alarms to get their input on methods to prevent alarm-related errors.”

•    ECRI, “Top 10 Health Technology Hazards, 2015” 
•    ECRI, “Evaluation Background: Ancillary Alarm Notification Systems” 
•    HealthLeaders Media“Clinical Alarm Safety Improvements Are a Team Effort”
•    PSQH, “Alarm Management: First Things First

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