In 2003, the Methodist Hospital System (Houston, TX) upgraded its incident reporting processes by implementing the Patient Safety Net from the University Health System Consortium. In addition, the biomedical engineering department developed an in-house database to track and document its efforts. Establishing this database led to the discovery that very few devices that had been involved in incident reports were being properly sequestered. This meant that suspect devices might end up being used on patients.

The first step in remedying this problem was to set specific criteria for proper sequestering—namely, the device must be appropriately removed from service, accessories and supplies must be saved with the device, and the device must be properly labeled to indicate it was involved in an incident. The department then analyzed reported incidents to identify trends in sequestering processes and establish a performance baseline against which to measure progress.

From there, the department began a training program that was combined with a sticker system for identifying devices to be sequestered. Early results were promising, but compliance quickly fell off, even after refresher training. Partnering with risk management, biomedical engineering developed the acronym STARR as a guide to correct sequestering: Sequester, Tag, place in a secure Area, Report in the Patient Safety Net, and Report to biomedical engineering. In conjunction with central supply, biomedical engineering also improved the availability and consistent placement of the stickers. And a description of the STARR system was added to the employee handbook to ensure that new employees were aware of it.

As a result of this program, rates of proper sequestering improved significantly—from 72% in 2006 to 95% in 2007. And the hospital found that the training in sequestering also increased staff awareness of the entire process of reporting medical device problems.

This project earned the Methodist Hospital System recognition as a finalist for the 3rd Health Devices Achievement Award, issued by ECRI Institute in 2008 to honor excellence in health technology management. Learn about the other submissions that achieved recognition.