- EHRs may be changing the healthcare industry at a lightning pace, but it appears that the patient safety downsides of health IT, including alarm fatigue and workflow struggles, remain sadly the same. These issues, along with patient monitoring and surveillance shortfalls, have consistently camped out on the annual ECRI Institute Top 10 Health IT Hazards list, and are likely to continue to plague the industry in 2016.
"With all of the issues that hospital leaders are dealing with, technology safety can often be overlooked," says Anthony Montagnolo, chief operating officer at the ECRI Institute. "Based on our experience with independent medical device testing in our laboratory, accident investigations, and reported events, we're very aware of serious safety problems that occur."
After a shocking series of patient deaths due to improperly cleaned reusable endoscope devices, the difficult-to-clean equipment snagged the unenviable top spot on this year’s hazards list. Insufficient staff education or haphazard processing before reuse can contribute to the spread of deadly carbapenem-resistant Enterobacteriaceae (CRE) infections, the list warns.
Alarm fatigue, misuse, and frustration have figured highly on the list for several years, prompting concerns that electronic health record features that hope to be helpful are actually doing more harm than good.
“Failure to recognize and respond to an actionable clinical alarm condition in a timely manner can result in serious patient injury or death,” ECRI states. Patients face safety risks in a number of different circumstances: when an alarm-worthy condition is not properly detected by a medical device, when the condition is detected but not properly communicated to the provider, or when the provider receives an alarm or alert but chooses to dismiss, ignore, or override the warning.
“Addressing clinical alarm hazards in all their forms requires a comprehensive alarm management program that includes stakeholders from throughout the organization,” the list adds.
Coupled with poor EHR workflow design and execution, which took the sixth spot on the hazards list, improperly configured alarms can do more than just delay a treatment or open up an opportunity for an adverse drug event (ADE). An overwhelming cacophony of alarms can contribute to physician burnout and even lead some physicians to quit their jobs, a 2014 study found.
“[EHR alerts] likely represent one of the most frustrating components of EHRs for providers,” says the study, published in the American Journal of Managed Care. “Compared with paper communication systems, they are perceived to ‘increase the number of work items, inflate the time to process each, and divert work previously done by office staff to them.’”
“Other work has shown that providers perceive many of the alerts they receive to be unnecessary, and has documented variable physician acceptance of features like computerized reminders and electronic alerts,” the authors continued.
An industry survey published in the Journal of the American Medical Association in 2013 noted that 87 percent of physicians believe that EHR alerts are “excessive” and disruptive, so much so that they tune out the majority of noises and pop-ups they experience during the care process. Physicians reported receiving a median of 63 alerts per day, and had trouble separating critical reminders or warnings from more routine information.
In the same survey, providers noted that they did not receive adequate training or workflow support that would help them to make the best use of their EHR systems. Convoluted workflows, and their subsequent shortcuts and workarounds, can cause well-meaning providers to fragment a patient’s medical record by documenting information incorrectly within the EHR – or even turning back to paper in a pinch.
“Poor alignment between the configuration of a health IT (HIT) system and a facility’s workflow increases the opportunity for medical errors, putting patients at risk,” the ECRI list says.
“Problems can arise if the HIT system is not configured to support the processes and workflow used in a particular care area, or if the workflows and standard operating procedures are not adjusted to accommodate the capabilities of HIT systems.”
Other common errors include the incorrect application of default values for dosing, time, or orders, and other input errors that can cripple an organization’s data integrity efforts.
“Any of the above problems can result in patient harm due to delayed, incorrect, or undelivered therapies,” the report adds. “Facilities should consider configuration issues during the HIT system selection phase and should modify and validate workflows to confirm that they align with the system’s capabilities.”
These complications can also contribute to improper monitoring and surveillance of patients, which comprise two other entries on the list. Additionally, ECRI notes that incorrect use of USB ports for connecting medical devices can cause monitoring failures if the device does not work as intended, resets itself to default values, does not trigger necessary alerts, or fails to deliver therapies.
“Uncontrolled access to medical device USB ports could also lead to a security breach, putting the patient’s data and the healthcare facility’s systems at risk,” the report points out.
Additional patient safety hazards highlighted by the report include unsafe injection practices that may expose patients to infection, inadequate training for operating room staff and ventilator technicians, mechanical failures of gamma cameras that can cause significant injury or death, and failure to effectively monitor postoperative patients for opioid-induced respiratory crisis.