Alarm fatigue, radiation overexposure among most dangerous health IT risks

Two seemingly innocent, everyday occurrences at hospitals--alarms and CT scans--are among the most dangerous technology hazards, according to a new ECRI Institute report. For all the countless benefits that technology provides, ECRI warns of the top 10 hazards for 2012, including alarm fatigue and overexposure to radiation therapy and CTs, similar to last year's list.

There are a variety of alarm hazards, including the much talked about "alarm fatigue," in which providers grow numb or turn the volume down on sounds because of an overwhelming number of alerts, causing delayed responses. Staff also may not be able to distinguish the urgency of each alarm or may forget to restore the active setting when a patient returns to the floor for testing.

"It's elementary psychology that ubiquitous warnings desensitize people. Think of the retail security alarms that are always going off in drugstores, and how often clerks disregard them," an Atlantic article mentioned yesterday.

ECRI recommends conducting organization-wide assessments and setting up alarm management programs. For example, establish alarm notification and response protocols by clearly assigning which staff member is responsible for what alarm, as well as back-up responders so that someone is always available. Also, establish policies to control alarm silencing, modification, and disabling.

In addition to alarm hazards, the report names radiation exposure as a risk, falling in line with the Joint Commission's Sentinel Alert about over-radiation. Both appropriate and inappropriate dose levels can lead to unnecessary radiation exposure, and most healthcare facilities do not routinely audit CT doses, according to the report.

While acknowledging there is no simple fix regarding radiation therapy and diagnosis, the report recommends appropriate oversight in quality assurance and quality control procedures, including developing checklists for each step of patient treatment, assessing whether existing equipment is adequate for today's treatments, and looking at staffing and training.

The ECRI report encourages healthcare organizations to prioritize safety risk by asking how harmful is a device, how likely is a risk, how widespread is that risk, and is it a high-profile problem.

For more information:
- check out the report (.pdf)
- read the Atlantic article

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