10 Worst Medical Treatment Dangers 2013

   Advances in health technology are often a double-edged sword. They provide new ways to improve patient care but also create new opportunities for harm if design flaws aren't identified and fixed, equipment isn't properly maintained, or safety and usage protocols aren't followed. To help minimize the chance of adverse events, ECRI Institute of Plymouth Meeting, Pennsylvania, an independent nonprofit organization that studies improvement to patient care, has named the Top Ten Health Technology Hazards for 2013.
   The hazards were chosen on the basis of potential for injury or death, frequency of occurrence, how many patients are affected, notoriety in the media, and measures hospitals can take to lessen these risks.

Alarm Hazards
   Alarms on infusion pumps, ventilators, and other devices are designed to inform medical staff of a problem that needs prompt attention. But the sheer number of alarms in a hospital can overwhelm staff, leading to complacency and delayed response. Caregivers often turn down the volume of alarms.
   "If too many alarms are sounding, then all alarms start to lose their meaning," said Rob Schluth, Senior Project Officer of ECRI's Health Devices Group. "Focus on reducing audible alarms for events that don't require action on the part of the staff. Perhaps a visual indicator is sufficient for some conditions.
   "Facilities can fix problems that cause alarms to sound in the first place," he said. "For example, reinforcing skin prep techniques and replacing electrodes on a regular basis can prevent ECG leads from coming off and thus prevent leads-off alarm conditions from developing."

Medication Administration Errors Using Infusion Pumps
   Infusion devices are the subject of more adverse incident reports to the US Food and Drug Administration than any other medical technology, according to the Association for the Advancement of Medical Instrumentation. From 2005 through 2009, more than 700 deaths associated with infusion devices were reported.
   Data-entry mistakes such as mistyping information or entering it into the wrong field can be dangerous. Errors are caused by illegible orders or drugs that are improperly prepared or given to the wrong patient.
   "It's essential to build in time and resources for clinical and technical staff to determine which data flows will meet clinical needs, and then develop and refine workflows, policies, and procedures around using the integrated system," said Erin Sparnon, Senior Project Officer in ECRI's Health Devices Group

Radiation Burns From Diagnostic Radiology Procedures
   Inappropriate use and dose levels of CT can lead to unnecessary radiation exposure for patients. Image quality typically improves as the dose increases. As a result, there is a tendency to use higher doses that are associated with greater risk to the patient. Acute reactions such as radiation burns and hair loss are relatively rare but still occur too frequently, the ECRI report states.
   Radiation-induced burns occur because the radiation beam may stay on the same area of skin for too long, said Jason Launders, Director of Operations of ECRI's Health Devices Group. "Alternative projections can reduce the incidence of burns," he said. "It is difficult to track the dose to a specific area of skin. Fluoroscopy systems keep track of the exposure time and alarm after a pre-set time. The alarms are usually ignored

Patient Data Errors in EHRs and Health IT
   Mistakes that cause one patient's data to end up in another patient's record aren't new.
   "Getting the right patient's data into the right record doesn't just happen automatically," said Rob Schluth. "It requires well-designed systems, careful implementations, and attention to workflow processes. For example, a physiologic monitor may be set up to transmit data to a patient's electronic health record. But what happens when the monitor is connected to a different patient? Or if that patient is moved to a different monitor? Correctly associating and disassociating a device with the patient's record are key steps in the process."

Devices and IT Systems That Don't Interface
   Interfaces between medical devices don't always function as intended and can allow dangerous conditions to exist. For example, ECRI found that one monitoring system didn't communicate audible or visual alarms from an interfaced ventilator to warn caregivers of a critical patient circuit disconnection.
   "Interoperability provides a pathway for good things to be shared across devices and systems," said Rob Schluth. "Patient data and test results can be transmitted without lengthy delays or the need for repeated data entry. Bad things can also travel along those pathways. A fault in one system could affect other connected systems. A pathway could be incomplete, meaning that some vital information isn't transmitted.

Air Embolism Hazards
   Intravascular air embolism is a potentially lethal complication of certain medical and surgical procedures. While relatively rare, fatal incidents do occur. The Pennsylvania Patient Safety Authority found 59 confirmed or suspected air embolism adverse events from 2004 through 2011, including 7 cases of permanent harm and 6 deaths. The largest percentage of reported events is associated with the use of central venous access devices.
   "It's hard to say whether incidents are because of complacency, because specific individuals didn't understand the risks in a particular situation, or because of an unusual combination of factors," said Rob Schluth. "These incidents illustrate that even well-known hazards warrant attention to remind caregivers of the risks, as well as steps to take to minimize them."
   ECRI recommends instituting a time-out procedure for activities that present a high embolism risk, reinforcing the appropriate procedures to follow for removing air from solution delivery systems, and requiring clinicians to trace any line to its source before connecting the line to a patient's IV access device

Using Technology for Adults on Children
   Technology designed for adult patients often needs to be used on children, in some cases because no alternatives exist. Pediatric-specific devices are slow to reach the market because of the small numbers of patients available to study, the devices' high-risk nature, and high development costs.
   Children can be placed at risk when "adult" technologies need to be used in their care. Examples include the use of inappropriate dose settings during radiology procedures, a lack of child-appropriate selection options in medication administration and computerized provider order-entry systems, and the absence of pediatric emergency supplies in care areas where children may be seen.
 

Dirty Endoscopes and Surgical Instruments
   Cross-contamination hazards that occur when flexible endoscopes aren't properly reprocessed have been on ECRI's top 10 hazards list for years. ECRI wants facilities to address the reprocessing function more broadly in their patient safety efforts. Numerous reported incidents involved "dirty" instruments being processed for use in surgery and other medical procedures. The contamination was often not detected until after the item had been used on a patient.
   "It's important that reprocessing staff be taught proper protocols," said Rob Schluth. "It is helpful to explain why each step is needed, describing exactly what can happen if a step is skipped. Frontline workers need to be aware of the hazards.
   "Look at the root causes for any failure. Is the issue that the staff doesn't know the correct procedure, or are other factors contributing to the problem?" he asked. "For example, is sufficient time allotted to perform the procedure correctly, or does staff feel pressured to take short cuts? Are the necessary supplies available? Are the instructions unclear or out of date? Is reprocessing too difficult because the device wasn't adequately precleaned in the procedure room?"

Texting While Performing Surgical Procedures
   Interruptions from pagers and other devices have long been part of medicine, but smartphones and other mobile devices now make it easier for clinicians to be interrupted for non-work-related reasons -- and to make their own interruptions.
   Half of the respondents to a 2010 survey of perfusionists acknowledged texting during heart-lung bypass procedures, with 15% further admitting that they accessed the Internet and 3% reporting that they visited social networking sites during procedures. Additional distractions occur more frequently than people think, exposing patients to danger.
   "These devices can be used for any number of clinically useful purposes," said Rob Schluth. "But they can divert the caregiver's attention away from the patient or the task at hand. Receiving personal text messages or using the devices to check social media during patient care are questionable behaviors. Even the act of focusing on the device rather than observing the patient, or listening to information being exchanged, can affect the quality of care."

Surgical Fires
   There are an estimated 600 surgical fires per year. Although that's only a miniscule percentage of the millions of operations performed, these almost entirely preventable events still occur too frequently. The hazard remains on ECRI's top 10 list because of the potential devastating consequences, including disfigurement and death.
   "A quick assessment of the potential fire risks before the start of a procedure can help staff guard against bringing together the elements of the fire triangle -- oxidizers, ignition sources, and fuel," said Rob Schluth.

End-of-Life Care Guidelines Updated

   The Hastings Center has updated and expanded its landmark 1987 consensus guidelines for ethical care of terminally ill patients. Oxford University Press published this second edition of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life.
   "As the population ages, more people are living with chronic diseases," Hastings Center President and guidelines working group member Mildred Z. Solomon, EdD, said in a news release. "Advances in medicine have created both benefits and burdens, including problems of quality, safety, access, and cost. We need to help patients and families better navigate their choices, and physicians and healthcare leaders must build systems of care that are wiser and more compassionate."
   The guidelines target all healthcare professionals involved in caring for terminally ill patients. They discuss ethical and legal options in the United States for use of life-sustaining technologies, offer comprehensive guidance on informing patients and surrogates of their options, and include detailed strategies to optimize healthcare delivery.
   Issues in end-of-life care include confusion and conflict over decision-making, poor patient–clinician communication, insufficient pain and symptom relief, and use of treatments offering minimal benefit. Consequences of poor care include reduced quality of life, greater family stress, and increased costs of healthcare without added value
   A physician's offer or a family's request to "do everything" may neither respect the patient's rights nor ensure good care. Recognizing religious, cultural, psychological, and social factors affecting medical decision-making can help clinicians provide appropriate, respectful care, according to the guidelines.
   "The guidelines offer a reliable framework for these discussions, and for education, policy-making, and redesign of care," lead author Nancy Berlinger, PhD, a research scholar at the Hastings Center, said in the news release. "They also encourage healthcare leaders and administrators to support better outcomes for patients by building more effective forms of care delivery and integrating care near the end of life into organizational safety and improvement initiatives."

Changes from the 1987 Guidelines
- Recommendations based on the past 25 years of "empirical research, clinical innovation, legal and policy developments, and evolution of professional consensus";
- discussion of decision-making for and about children near the end of life;
- issues specific to patients with disabilities, including the effect of their perspectives on physcian–patient communication and management decisions;
- recent evidence regarding brain injuries and neurological states, how they affect prognosis, and laypersons' misperceptions and unrealistic expectations due to media influences;
- information regarding physician-assisted suicide and how it differs from treatment refusal;
- discussion of controversy regarding palliative sedation;
- acknowledgement that cost is an ethical issue in healthcare decision-making;
- request that hospitals and healthcare organizations develop transparent policies on cost management to avoid bedside rationing; and
- integration of "the insights of ethics and law, medicine and other healthcare professions; the experience of patients and family caregivers; and patient advocacy."

   The 1987 edition of the guidelines set the ethical and legal framework for US medical decision-making and was cited in the Supreme Court's 1990 Cruzan decision. This established patients' constitutional right to refuse life-sustaining medical treatments and affirmed that surrogates could make decisions for patients lacking that capacity.
   In the news release, Kathleen M. Foley, MD, chair of the Society of Memorial Sloan-Kettering Cancer Center, refers to the new guidelines as "the sourcebook for how the ethics of life-sustaining treatment and care at the end of life should be taught, institutionalized, and translated into clinical teaching and practice."

End-of-Life Wishes: Lack of Communication Persists

Steven For Medscape

   Although many elderly patients and their families discuss advance care planning (ACP) with their physicians, those wishes often fail to be added to patients' medical records, according to findings from a study carried out in Canada and published online April 1 in JAMA Internal Medicine.
   "To our knowledge, there has been no rigorous audit or evaluation of ACP from the patient or family perspective using validated questionnaires that assess the frequency of engagement in key ACP activities," write Daren K. Heyland, MD, FRCPC, from the Clinical Evaluation Research Unit, Department of Medicine, Kingston General Hospital, Ontario, Canada, and colleagues.
   Aiming to fill that gap in knowledge, these researchers administered in-person questionnaires to 278 elderly patients who were deemed at high risk of dying during the subsequent 6 months. They also surveyed 225 family members associated with the patients. The patients were treated at 12 acute care facilities in Canada between September 2011 and March 2012. Their mean age was 80 years; family members were about 61 years of age.
   Responses to the questionnaires showed that before hospitalization, more than three quarters of the patients (76.3%) had given thought to end-of-life (EOL) care. Only 11.9% expressed a preference for life-prolonging care.
   Of the patients, 47.9% had completed advance care plans, and 73.3% had formally designated a surrogate individual to make decisions regarding their care.
   Even so, of the patients who had talked about their wishes with their families, less than a third (30.3%) had related those wishes to their family physician. Only a bit more than half (55.3%) had discussed their preferences with any member of their healthcare team.
   Of particular note, in only 30.2% of cases were patient/family wishes for EOL care documented in medical records.
   "Many elderly patients at high risk of dying and their family members have expressed preferences for medical treatments at the EOL," the authors write. "However, communication with health care professionals and documentation of these preferences remains inadequate. Efforts to reduce this significant medical error of omission are warranted."
   In an invited commentary that accompanies the article, Theresa A. Allison, MD, PhD, and Rebecca L. Sudore, MD, both from the Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, underscore the importance of communication between patients, their families, and medical providers.
   "Discussions about goals of care and code status constitute a medical procedure every bit as important to patient safety as a central line placement or a surgical procedure," they write. "Much as we have developed systems to improve patient safety in surgical procedures, we need to develop systematic approaches to discussing patient values and goals of care."
   This study was supported by funding from the Canadian Institutes of Health Research, the Michael Smith Health Services Research Foundation in British Columbia, Alberta Innovates, and the Alternate Funding Plan Innovation Fund in Ontario. The study authors and editorialists have disclosed no relevant financial relationships.

ADHD: Why Do the Numbers Keep Growing?

Thomas J. Power, PhD from Medscape

   A recent New York Times analysis of data from the most recent National Survey of Children's Health concluded that almost 1 in 5 teenage boys and 11% of all school-aged children have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Medscape asked Dr. Thomas Power, from the Children's Hospital of Philadelphia (CHOP), to discuss some theories to explain this increase.
   My name is Tom Power. I'm a psychologist and Director of the Center for Management of ADHD at CHOP. I want to make a few comments about the rising rates of ADHD. At this point, a number of people are commenting that the rates of ADHD may be over 10%. People are asking about factors that may be contributing to that [increase]. Probably the main reason is that providers generally are doing a better job of screening for ADHD. In particular, primary providers and school professionals are doing a better screening for ADHD and bringing to the attention of parents potential concerns about their children.
   The real estimates of ADHD, based upon a number of studies conducted by independent researchers, would suggest that the prevalence is probably in the 5% to 10% range. The best guess may be about 7%, which raises the question as to whether ADHD may be overdiagnosed at this point. I think that these are legitimate questions. Particularly in suburban communities in which more affluent, middle-class and upper-middle-class families reside, there may very well be an overdiagnosis of ADHD. The reasons for that are that a diagnosis of ADHD may be assigned after only a brief screening, which typically would not be appropriate. A comprehensive evaluation is necessary.
   In our center, the approach that we use includes parent and teacher rating scales, as well as a thorough parent interview, consisting of a good medical and developmental history. We strongly recommend that approach to providers in the community.
   Another potential concern is that children with mild problems may be assigned a diagnosis of ADHD. The presence of mildly elevated symptoms of inattention or hyperactivity is typically not sufficient to render a diagnosis of ADHD. There has to be a relatively high level of symptomatology, as well as significant impairment in 2 or more settings to render the diagnosis. I do want to mention that underdiagnosis is also still occurring in certain regions of the country -- in particular, rural areas and underserved inner-city locales. Urban areas are places in which the diagnosis of ADHD may not be made often enough and services may not be provided as much as they should.
   What can we do about the problem of overdiagnosis? First, we need to be conducting more comprehensive assessments, as I described. Second, when children have mild problems, they often need services. They may not need intensive services. They typically would not need medication. We would typically recommend brief parent training using behavioral strategies, perhaps consisting of 2-4 sessions, and school consultation using behavioral strategies. If those methods are not sufficient and the problems get to be more concerning, then more intensive behavioral treatments -- again, using parent training and school consultation -- would be indicated. In some cases, medication, in particular with stimulants, is necessary.