The difficulty of removing titanium rings

By Kim Smiley

Titanium rings have been growing in popularity because of their durability, strength, light weight and hypoallergenicity.  But unfortunately, the strength of titanium rings can become a problem if one ever needs to be cut off.  When a finger swells with a ring on it, blood flow to the finger is restricted and can cause tissue death in the finger so the issue of how to quickly and safely remove a ring can be quite serious.

Dr. Andrej Salibi, a plastic surgeon at Sheffield Teaching Hospitals in the U.K., recently described a case where a patient came to the ER after his finger swelled following a soak in a hot tub.  Normally, removing a ring from a swollen finger is a quick and relatively easy procedure, but in this case the patient was wearing a titanium ring and all the usual methods used to remove rings failed. Typically, a doctor would grab the ring cutter at this point and simply cut the ring off, but the titanium ring was too strong for a traditional ring cutter.  The fire department was called and attempted to use its own specialized cutting gear, but that also couldn’t cut through the titanium ring.  The patient had to be admitted to the hospital and spent (what I assume was a very uncomfortable) night with his hand elevated.

The next morning, the doctors decided to try something new – bolt cutters.  The bolt cutters finally cut through the metal, but the doctors still had to find a way to pull the metal apart. Using some large, heavy-duty paperclips, two doctors were able to pull the ring far enough apart that the man could slip his finger out.  Thankfully, the man’s finger is going to be fine with no long-term damage.

The bolt cutter solution worked so well, the doctors involved actually published a letter to share the idea with other physicians.  Bolt cutters are commonly available in a many hospitals, but not something that ER doctors may initially think to use.  There is other specialized equipment like dental saws or diamond-tipped saws which may be able to cut through titanium rings, but they aren’t generally readily available in a hospital setting and require more manpower to use.  The potential for accidentally injuring a patient’s finger during the removal process is also higher than with a simple bolt cutter.

Sometimes a simple solution can be the best solution and as this case study demonstrates, it is also important to document and share lessons learned.  Solving a single problem is a good thing, but sharing solutions so that the wheel doesn’t have to be reinvented the next time the problem is encountered is even better.  Maybe some doctor will read the letter published by the doctors involved in this case and a future patient will be spared an extra night of discomfort and unnecessary time in the hospital.

If you are in the market for a ring, you may want to consider carefully whether titanium is the right metal choice.  If you do choose titanium, you may want to stick with pure grade because it is significantly softer and easier to cut than aircraft grade, with has other metals mixed in.  It is also a good idea to remove all rings when working around machinery or if you notice your fingers swelling.

To view a Cause Map of this example, click on “Download PDF” above.

Medical Device Vulnerable to Hacking

By Kim Smiley

The Food and Drug Administration (FDA) made headlines when they issued a warning that a computerized pump used for infusion therapy, Hospira Symbiq Infusion System, has cybersecurity vulnerabilities. Hacking is scary enough when talking about a laptop, but the stakes are much higher if someone had the ability to alter the dosage of critical medication.

A Cause Map, a visual format for performing root cause analysis, can be used to analyze this issue.  The first step in the Cause Mapping process is to fill in an Outline with the basic background information, including how the issue impacts the overall goals.  Defining the impacts to the goals helps define the scope of an issue.  Once the Outline is completed, one of the impacted goals is used as the starting point to building the Cause Map itself.  For example, the potential risk of serious injury or death is an impact to the patient safety goal and would be the first cause box on the Cause Map.  The rest of the Cause Map is built by asking “why” questions and documenting the answers in cause boxes to intuitively lay out the cause-and-effect relationships.

So why is there potential for injury or death with the use of the Hospira Symbiq Infusion System?  It is possible for a patient to receive the incorrect dosage of medication because the system could be accessed remotely by an unauthorized user who could theoretically change the settings.  There have been no reported cases where this infusion pump system has been hacked, but both Hospira and an independent researcher have confirmed that it is possible.

This system is vulnerable to hacking because it is designed to communicate with hospital networks and the design has a software bug that could allow it to be accessed remotely via a hospital’s network.  The infusion system was designed to interface with hospital networks to help reduce medication dosage errors because the dosage information wouldn’t need to be entered multiple times.

The final step in the Cause Mapping process is to develop solutions to help reduce the risk of similar errors in the future.  In this specific example, the FDA has strongly encouraged healthcare facilities to transition to alternative infusion systems as soon as possible.  Hospira discontinued this specific design of infusion system in 2013, reportedly due to unrelated issues, but it is still available for sale by third-party companies and used by many healthcare facilities. There will not be a software patch provided or any other means to make the Hospira Symbiq Infusion System less vulnerable to hacking so the only option going forward will be to switch to a different infusion system. During the time required to transition to new equipment, the FDA has provided specific steps that can be taken to reduce the risk of unauthorized system access that can be read here.