We take for it granted that technology can be used to tag objects in various ways, useful and otherwise. The anti-theft devices used on retail clothing stores are a familiar example. Radio Frequency Identification Devices (RFID) are used for this purpose as well as for security access. I have a device like that on my windshield for automatic highway tolls on the turnpike. Hospitals also have a strong interest in keeping track of lots of items like pharmaceuticals, equipment or even ordinary sponges used in surgery. Counting and keeping track of sponges is routine so none are inadvertently left in the patient. Tagging sponges with little RFIDs is just one obvious use. But a new study published in the Journal of the American Medical Association (JAMA. 2008;299(24):2884-2890) by a group of Dutch researchers raises some serious questions about indiscriminate RFID use in the high tech hospital setting:
Remko van der Togt, M.Sc., of Vrije University, Amsterdam, the Netherlands, and colleagues conducted a study in a controlled, non-clinical setting to assess and classify incidents of electromagnetic interference by RFID on critical care equipment. The tests were performed in a one-bed patient room in an intensive care unit (ICU) and with no patients present. Electromagnetic interference by two RFID systems (active [with batteries and ability to transmit information] and passive [without batteries, information retrieved by RFID reader] was assessed in the proximity of 41 medical devices (in 17 categories, 22 different manufacturers). The devices included items such as external pacemakers, mechanical ventilators, infusion/syringe pumps, dialysis devices, defibrillators, monitors and anesthesia devices. Incidents of EMI were classified according to a critical care adverse events scale as hazardous, significant, or light.
All 41 medical devices were submitted to 3 EMI tests resulting in 123 EMI tests. A total of 34 EMI incidents were found; 22 were classified as hazardous, 2 as significant, and 10 as light. The passive signal induced a higher number of incidents (26 in 41 EMI tests; 63 percent), and hazardous incidents (17), compared with the active signal.
Hazardous incidents included: total switch-off and change in set ventilation rate of mechanical ventilators; complete stoppage of syringe pumps; malfunction of external pacemakers; complete stoppage of renal replacement devices, and interference in the atrial and ventricular electrogram curve read by the pacemaker programmer. (AMA Press Release, hat tip Medgadget)
We now know this can happen. What makes the think it will happen is how all this gets done in a hospital. The business types are keeping track of the equipment and inventories, the lawyer types are trying to reduce the risk of errors and malpractice, the police types are trying to prevent drugs from being diverted. And what type is thinking about how all this is related to everything else? The median distance for a major interference was just under 10 inches.
There is an accompanying editorial in JAMA (2008;299(24):2898-289) by Don Berwick goes directly to the point:
From the particular case of RFID and EMI, therefore, emerge 2 important lessons. First, design in isolation is risky; even the most seductive technology will interact in the tightly coupled health care world in ways physicians and other members of the health care team had better understand, or they and their patients may pay a dear price. Second, no matter how good the design, in the end the battle for high safety and reliability in health care is never won. Safety is not a condition, it is a process. It can only emerge continually in a culture that is alert, cooperative, transparent, and resilient when the unexpected happens, as it always will. (JAMA)
As health care dollars become scarcer it becomes more and more likely there will be investment in keeping track of money rather than keeping track of bad things that happen to patients. It’s clear where the incentives and disincentives are in this. Certainly not in things that make the hospital culture more “alert, cooperative, transparent, and resilient when the unexpected happens.”