Up close and personal with ECRI and technology hazard prevention

por Lauren Dubinsky, Senior Reporter | February 02, 2017
HTM Infection Control Medical Devices Risk Management
Juuso Leinonen explaining potential
infusion pump malfunctions
Earlier this week, HCB News visited ECRI Institute in Pennsylvania to get a deeper understanding of the items on its annual list of the top health technology hazards for 2017.

The topics on the list are chosen by weighing factors such as the severity, frequency, breadth, insidiousness, and profile of the hazard — and they all have at least one thing in common: they can be avoided with appropriate measures.

"Technology safety can often be overlooked when hospital leaders are dealing with so many other issues," said David T. Jamison, executive director of ECRI's Health Devices Group, in a statement. "As an independent medical device testing laboratory and investigator of technology-related incidents, we know what can go wrong and what steps hospitals can take to reduce patient harm, related to specific technologies and processes."
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A different perspective on infusion pump danger

Infusion pump errors made it to number one, but this time for a different reason. In the past there was a focus on software safety features and integrating the pump with the EMR, but this time around ECRI is bringing attention to common nurse practices that are overlooked.

“These are all things that are simple and don’t cost anything, and nurses have been doing them for 20 to 30 years,” Erin Sparnon, manager of the Health Devices Group at ECRI, said in a workshop. “But sometimes it can be forgotten if they’re spending so much time thinking about the new technology.”

Sparnon recommends that nurses check the drip chamber in order to ensure that the infusion is flowing at the correct rate. For example, if the pump says that the flow is 30 milliliters per hour but it looks like 1,000 milliliters per hour then clearly there is an issue here that needs fixing.

Even though the automatic free flow clamp closes off the infusion when the set is being removed, the nurse should use the roller clamp as well. The nurses should also inspect the pump for damage before starting an infusion.

Sparnon said that nurses should ask themselves these questions:

  • Are there any cracks on the outside of the door?

  • When the door is open, does it look right or is something hanging to the side?

  • When loading the administration set, does it feel right or does it feel like something is jammed?

“Infusion pumps are one of the most numerous devices in the hospitals. We have hundreds or even thousands of these scattered across the hospital,” said Juuso Leinonen, project office of the Health Devices Group at ECRI. “They are oftentimes subject to pretty rough handling, and as a result you may have damage to various parts of the pump.”

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