By ASET and ABRET staff
In today’s complex healthcare environment, risk professionals face growing responsibility to ensure patient safety, reduce liability exposure, and maintain regulatory compliance. One area often overlooked is the neurodiagnostic (ND) lab. Yet, ND tests pose a variety of clinical and procedural risks that demand greater awareness, emphasizing the need for ND technologists to receive credentials and continuing education. In neurodiagnostics, where the tools used can influence the diagnosis of life-altering conditions, competence should not be optional.
The Risks Associated with Neurodiagnostic (ND) Testing
ND tests—such as electroencephalograms (EEGs), long-term monitoring (LTM), evoked potentials (EPs), nerve conduction studies (NCS), polysomnograms (PSG), and intraoperative neurophysiological monitoring (IONM)—are instrumental in diagnosing neurological disorders, including seizures and stroke. Patients undergoing these procedures are already at high risk for falls, but risks spike when activation procedures such as hyperventilation, sleep deprivation, and photic stimulation are added, or when electrodes are applied or implanted surgically for multi-day recordings during inpatient admissions to an epilepsy monitoring unit.
The risks associated with these activation procedures include transient hypotension, cerebral vasoconstriction, and infection. Other risks include:
- Extended electrode placement or improper electrode disinfection may lead to skin breakdown or cross-contamination.
- Incorrect lead placement may cause misinterpretation of test results.
- Inadequate artifact identification and troubleshooting could hide critical events or result in failure to detect significant abnormalities such as seizure onset or subclinical seizures.
With all ND tests, failure to recognize and respond to emergent events, such as airway obstruction, cardiac arrhythmias, or seizures, can result in patient injury, status epilepticus, hypoxic brain damage, or death.
For ND procedures performed in the operating room, there are additional risks to consider. While the goals in IONM are to prevent catastrophic outcomes by monitoring critical structures at risk during surgery, any delayed escalation of critical findings (e.g., seizures, hypoxia, significant EEG changes, IONM alerts) or inaccurate or incomplete documentation creates a threat for patients and medical-legal vulnerability for both the employer and employees involved.
Why Definitions Matter and the Realities of Liability
In 2023, four national neuroprofessional organizations issued a joint position statement listing job titles with corresponding qualifications and supervision requirements, along with a guidance document, Guidelines for Qualifications of Neurodiagnostic Personnel (QNP). The QNP recognizes that “the quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level.”
This national collaboration effectively establishes a standard for the neurodiagnostic industry, which is not governed by licensure. Consequently, when ND procedures are performed by insufficiently trained or uncredentialed personnel, legal scrutiny focused on job titles, best practices, and competency standards can be intense in cases involving patient injury or death.
Potential liabilities related to neurodiagnostic testing include:
- Negligent performance: Errors in test execution and equipment malfunction.
- Failure to follow best practices: Improper patient preparation or positioning, and incomplete or inaccurate documentation.
- Failure to obtain informed consent: While obtaining consent may be the neurologist’s responsibility, verification of the patient’s understanding of the procedure is a component of the technician’s responsibilities.
Risk Mitigation Strategies Specific to the ND Environment
1. Follow Overall Risk Management Best Practices
Ensure safeguards are in place to mitigate negligent performance, including errors in test execution and equipment malfunction, through competency validation and routine equipment checks. Prevent departures from best practices by enforcing proper patient preparation and positioning, as appropriate, along with complete, accurate, and timely documentation.
While informed consent is typically the physician’s responsibility, technologists should verify the patient’s understanding of the procedure and identify any concerns prior to testing.
2. Require Professional Credentials
Patients assume the person performing their diagnostic test is competent and has been properly vetted by their employer. One of the most effective ways to safeguard patients and institutions is through strong credentialing grounded in ongoing employer-measured competence.
Education and competency validation do not just enhance performance; they can also reduce clinical and organizational risk. National credentialing examinations exist within the ND field and, when combined with skills-based assessments, should be required by employers as a measure of true clinical competence.
High-quality credentialing ensures professionals demonstrate the knowledge, judgment, and real-world competence required to deliver safe and accurate neurodiagnostic testing.
Although credentialing is not legally required in neurodiagnostics, it is highly recommended by national professional societies. Position statements and published best practices support credentialing and may be used to evaluate questionable performance.
Many employers require credentials, which can be verified through neurodiagnostic credentialing bodies such as:
- ABRET — Neurodiagnostic Credentialing and Accreditation
- Board of Registered Polysomnographic Technologists
- Nerve Conduction Association (AAET)
- American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM)
These organizations establish that neuroprofessionals possess the required knowledge and skills and continue to evolve with the demands of their profession. Credentials are available in EEG, evoked potentials, long-term EEG monitoring, intraoperative monitoring, magnetoencephalography, autonomic testing, neuroanalysis, nerve conduction studies, and polysomnography, along with microcredentials that support incremental learning.
3. Use Shared Terminology
Many disparate terms are used by technologists, supervisors, and human resources departments. Variations in department names (e.g., EEG Department, Neurophysiology Lab, Neurodiagnostic Department) and job titles (e.g., EEG Tech, LTM Tech, Monitoring Tech) can negatively affect legislative efforts to establish licensing requirements, codify scope of practice, and advocate for the profession.
Legislators often look to national organizations for guidance when crafting legislation and regulations. Accordingly, ASET has implemented the QNP’s terminology in its advocacy efforts to accurately and effectively educate policymakers about the role of neurodiagnostic technologists.
4. Strengthen Training Opportunities
In addition to hiring exam-eligible trainees or credentialed ND technologists whenever possible, organizations should ensure a strong infrastructure for in-house training support.
Many regions face a shortage of qualified candidates, making it essential for employers to establish or adopt formal training programs to cultivate a credentialed workforce. Some hospitals and organizations address this need by using the Core EEG Curriculum to fulfill didactic requirements while providing clinical instruction.
Employers often supplement these programs with:
- Clinical competency assessments
- Attendance at formal lectures
- Participation in patient rounding (particularly in epilepsy monitoring units)
- Board preparation activities
5. Standardize Protocols for Emergent Event Recognition and Escalation
Given the high-risk nature of neurodiagnostic procedures, particularly during activation techniques and intraoperative monitoring, organizations should implement standardized, evidence-informed protocols for identifying and escalating emergent events.
These protocols should include clear thresholds for:
- Notifying physicians
- Activating rapid response teams
- Documenting time-sensitive findings such as seizure onset, EEG suppression, hypoxia, or significant IONM changes
Simulation-based training and competency validation can help ensure technologists respond consistently and appropriately under pressure. Standardization reduces variability in care delivery and strengthens defensibility in the event of adverse outcomes.
6. Implement Robust Quality Assurance (QA) and Audit Programs
Ongoing quality assurance processes are essential for identifying performance gaps before they result in patient harm. ND labs should establish routine audits of key risk areas, including:
- Electrode application practices
- Infection prevention measures
- Documentation accuracy
- Artifact recognition
- Test interpretation support
Peer review of studies—particularly those involving abnormal findings or clinical complications—can help identify trends and reinforce best practices. Data generated through QA activities should be trended over time and reported to leadership, creating transparency and enabling proactive risk mitigation.
Conclusion
Implementing effective mitigation strategies—especially ensuring that neurodiagnostic technologists are credentialed—is about increasing accountability, integrity, and patient protection within the neurodiagnostic environment. It is also about cultivating a future in which safety, trust, and excellence are expected.
This article was developed by ASET and ABRET for educational purposes and is not intended as clinical or legal advice.