Children’s Nebraska’s Award-Winning Approach to Recall Management

Challenge

Children’s Nebraska was faced with a critical patient safety challenge when it received an urgent alert from ECRI—four weeks ahead of the official FDA recall notification—warning of a potential defect in several Teleflex endotracheal tube products. The alert identified a serious risk: the 15 mm connector could detach from the endotracheal tube, potentially leading to oxygen desaturation and long-term harm to patients. Children’s Nebraska was under pressure to act swiftly, as its internal policy required all critical alerts to be investigated and addressed within one business day.

Solution

Rapid Identification and Response to Affected Product

Upon receiving the hazard notification, Children’s Nebraska acted immediately to safeguard patient safety. Leveraging ECRI’s Recall Management Automatch tool, the hospital efficiently identified endotracheal tube products impacted by the alert. Automatch automatically cross-referenced the affected items with the hospital’s inventory, eliminating the need for time-consuming manual review of purchase order records. This enabled the team to quickly pinpoint, isolate, and discontinue use of the defective products—ensuring a prompt and effective response to a critical safety threat.

Coordinated Communication Across Impacted Departments

Children’s Nebraska utilized ECRI’s Recall Management System to rapidly distribute critical information and documentation through its centralized electronic platform. This streamlined approach enabled immediate, coordinated communication among the six affected departments—Operating Room, Outpatient Surgery, Anesthesia, Education, Strategic Analysis, and Value Analysis—facilitating swift collaboration and unified action in response to the recall.

Timely Remediation and Minimal Disruption to Care

After assigning the recall to the appropriate departments, Children’s Nebraska swiftly implemented corrective actions while maintaining full visibility to progress through the ECRI system. This real-time tracking enabled teams to address the issue efficiently and ensure minimal disruption to patient care. By leveraging Automatch, Children’s Nebraska successfully met its internal policy of resolving critical alerts within one business day—demonstrating a strong commitment to patient safety and operational excellence.

Results

Thanks to the early alert from ECRI, Children’s Nebraska’s Value Analysis team was able to act swiftly, collaborating with suppliers and clinicians to identify suitable product substitutes one month before the broader FDA recall was announced. This proactive approach gave the organization a critical head start in sourcing substitutes, minimizing supply disruption, and ensuring continued patient care without delay.
This success story highlights the vital role of a robust, technology-driven recall management system. Children’s Nebraska’s proactive approach, strong internal protocols, and unwavering commitment to patient safety earned them ECRI’s 2024 Recall Management Award—recognition well-deserved for their leadership in healthcare safety and efficiency.