Data Integrity, Networked Devices Among Top Health IT Hazards for 2014

By Nathan Eddy

Ventilators, infusion pumps and many other devices generate clinical alarms to help caregivers keep patients safe, but excessive numbers of alarms can lead to fatigue, and patients could be put at risk if an alarm does not activate when it should. Alarms can also distract caregivers from paying attention to more important patient care activities.

Although invaluable, these devices also represent a large technology management burden, as a hospital may have hundreds or even thousands of these devices in its inventory, and device failures—or failures to use the devices properly—are not uncommon and can cause significant patient harm, the report noted. Infusion pump integration—that is, connecting the servers for the infusion pumps with other information systems—can provide additional protections.

CT practices that can place children needlessly at risk include the inappropriate use of any technology that uses ionizing radiation, as well as the failure to properly control the radiation dose during such procedures. The report said efforts should be made to minimize a child’s exposure to high doses of ionizing radiation.

The presence of incorrect data in EHRs and health IT systems can lead to incorrect treatment, potentially resulting in patient harm. The report points out the myriad ways that the integrity of the data in an EHR or other health IT system can be compromised.

Knowledge of the risks and experience in executing precautions may be lacking—a situation that could lead to unnecessary radiation exposures to clinicians working in a hybrid operating room (OR) on a daily basis, the report warned.

The report warned that successful reprocessing of any device requires consistent adherence to a multistep procedure. Failure to properly perform any step, including some necessary manual tasks, could compromise the integrity of the process and lead to significant patient harm. Staff should be trained in these protocols, and they need adequate space, equipment and instructional materials.

One underappreciated consequence of system interoperability is that updates, upgrades or modifications made to one device or system can have unintended effects on other connected devices or systems, like a facilitywide PC operating system upgrade that causes the loss of remote-display capability for a hospital’s fetal monitoring device.

Due to their smaller size and ongoing physiologic changes, children may suffer adverse effects when subjected to adult-oriented health care techniques. The report warns that medication dosing errors can be particularly harmful to children because of the patient’s small size.

Initial training provided by the supplier of a robotic system can help users become familiar with it, but it does not teach trainees how to perform specific surgical procedures. Thus, it is up to the hospital to verify that surgical staff members have the necessary procedure-specific skills.

Last appearing on the list in 2010, a string of incidents prompted the organization to include retained surgical items (RSIs) as a 2014 top risk. Risks to patients can include prolonged or additional surgery, as would occur when an RSI is discovered and its removal is deemed appropriate, or future complications, some potentially serious, as could occur when an RSI leads to infection or causes damage to the surrounding tissue.