Patient Safety: Vigilance, Cyber Awareness, and Take Action

Regulatory requirements, such as The Joint Commission and the Occupational Safety and Health Administration require safety inspections be carried out at regular intervals to assure patient safety. The Nurse Practice Act also requires nurses to safely operate all equipment and use medical devices properly during patient care. When new equipment is introduced to a patient care area, a competency verification should be conducted of the responsible staff who will be using the equipment. This competency verification is typically maintained in the personnel file of the employee for future reference if necessary.

Nurses are taught at some time during their training to always look at the electrical cords of all equipment because a frayed cord is a potential fire hazard. This remains to be true. The temperature of solutions used in heating and cooling pads or blankets may also pose a risk of injury to the patient if the fluid is too hot or too cold. Burns have resulted from improper regulation of temperature associated with a variety of patient care treatment devices. As crazy as it may sound, a simple non-invasive blood pressure cuff has caused patient harm. The device inflated to extreme pressures intermittently over a period of time that ultimately caused permanent nerve damage to the patient’s arm resulting in a clawed hand. A list of equipment frequently involved in patient care issues includes, but is not limited to, the following: volumetric infusion pumps, patient controlled analgesic pumps, blood glucose testing devices, heating pads, cooling/heating blankets, non-invasive blood pressure cuffs, nasal cannula tubing, leg immobilizers, patient lifts, and continuous positive airway pressure machines. An injury exposing the Achilles tendon of an elderly person resulted from a leg immobilizer. The patient’s skin was not checked on a regular basis and as ordered by the physician for breakdown.

Cyber Risk

It seems obvious that inspecting equipment and / or medical devices on periodic regular intervals is a patient safety issue. Inspecting or evaluating the proper functioning of medical equipment should be an added consideration at the time of, or immediately following a rapid response event. We live in a world where amazing cyber technology exists therefore, health care providers must now consider the possibility that technical equipment may have malfunctioned which may have originated from a cyber source. This possibility would never have been considered before. Hacking Healthcare IT in 2016 was published by the Institute for Critical Infrastructure describing how devices that are blue-tooth enabled and have access to the internet, such as automatic implantable cardioverter-defibrillator and pacemakers, patient controlled analgesic pumps, and insulin pumps are at risk for being hacked or reprogrammed.

Take Action:

1. Be hyper-vigilant and open to possibilities of contributing factors never considered before.

2. Conduct a survey of the equipment in the room at the time of the event and inspect it carefully as soon as possible after a Rapid Response or a Code situation. If in doubt, take equipment out of circulation; send it to biomedical engineering for inspection and record your action on an incident report, occurrence report, or a variance report (whatever your institution may call the form). Let the professionals trained in biomedical engineering determine when to return the equipment of concern back to available inventory.

3. Double check the medication rates programmed in the infusion pumps. Sometimes the programming is not correct and guess who is going to held accountable? That’s right You! Double check the pumps by calculating the math yourself.

4. Record the temperature on any equipment or device that displays a temperature. For example: fluid warmers, blanket/pad warmers, heating/cooling blankets, crib warmers, etc. When the temperature is recorded, the medical record conveys that the health care provider was paying attention to details which will support your clinical competence should it be questioned.

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