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Technology and Its Unintended Consequences

Newer electronic devices can induce potentially hazardous incidents in critical care medical equipment.

Radio frequency identification (RFID) systems such as security access cards and electronic toll units on car windshields have become increasingly common in everyday life. Now, they also are being used in medicine to do all sorts of things, such as tracking surgical sponges, preventing drug counterfeiting, and monitoring blood products. But, as with any new technology that develops rapidly, unintended consequences are bound to happen. RFID systems potentially can induce electromagnetic interference that affects the performance of electrical equipment. This is problematic in intensive care units, where many electronic medical devices are present, and patients are less likely to tolerate adverse consequences of electrical glitches.

In simulations that did not involve patients, investigators studied the effects of two different types of RFID systems on 41 medical devices that are used commonly in critical care settings (e.g., infusion pumps, mechanical ventilators, external pacemakers). During 123 tests, the investigators documented 34 incidents of interference. Each incident was rated as hazardous (e.g., total stop of a syringe pump), significant (e.g., abnormal monitoring of blood pressure), or light (e.g., monitor disturbance that didn’t require attention). Of the 34 incidents, 22 were hazardous, 2 were significant, and 10 were light. The median distance between RFID readers and medical devices in all interference incidents was 30 cm (about 1 foot).

Comment: In a controlled nonclinical setting, RFID systems induced potentially hazardous incidents in medical devices. Although the researchers tested devices from only two manufacturers, we can infer that they are similar to the devices that are currently in clinical use. Although RFID systems will be important for the future of healthcare, an editorialist rightfully points out that a coordinated effort on the part of hospitals, regulators, and manufacturers is necessary immediately to ensure the safety of patients as this new technology develops.

— Neil Winawer, MD

Published in Journal Watch Hospital Medicine July 7, 2008

Citation(s):

van der Togt R et al. Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment. JAMA 2008 Jun 25; 299:2884.

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Berwick DM. Taming the technology beast. JAMA 2008 Jun 25; 299:2898.

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• Medline abstract (Free)