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Top 10 Health Technology Hazards

Dirty endoscopes top the list

The annual list of health technology hazards from the ECRI Institute identifies the potential sources of danger that warrant the greatest attention for hospitals in the coming year. Eight of the top 10 hazards for 2016 are new to the list.

1. Inadequate Cleaning of Flexible Endoscopes

The failure to properly clean and disinfect flexible endoscopes can spread deadly pathogens. ECRI says a critical step in the disinfection process includes cleaning biological debris and other foreign material from the endoscope before disinfection/sterilization. If this "precleaning" is not done, the disinfection/sterilization may not be effective.

2. Missed Alarms

The failure to recognize or respond to a clinical alarm can result in patient injury or death. Specifically, the ECRI noted that patients are put at risk when:

  • An alarm is not detected by a medical device, such as a ventilator or infusion pump.
  • The condition is detected but not communicated to medical staff.
  • The condition is communicated to medical staff, but action is ignored or delayed, or the response is bungled.

3. Failure to Effectively Monitor Patients for Opioid-Induced Respiratory Depression

Inpatients taking postoperative opioids are at risk of experiencing drug-induced respiratory depression, which can result in brain injury or death. Even healthy patients are at risk if they are taking another sedative, have comorbidities that predispose them to respiratory problems (such as obesity or sleep apnea), or are accidentally overmedicated.

Intermittent spot checks of oxygenation and ventilation every few hours are inadequate. The ECRI recommends adopting protocols from the Anesthesia Patient Safety Foundation and from the Joint Commission.

4. Inadequate Surveillance in a Telemetry Setting

Poor surveillance of monitored patients in telemetry can expose them to harm or even death. Factors contributing to the problem include:

  • Incorrect assumptions that monitoring systems will detect all potentially lethal arrhythmias.
  • Using telemetry monitoring with sicker patients in care areas with higher nurse-to-patient ratios.
  • Displaying patient monitoring information only at the central station, where it can be missed if staff isn’t there.

The ECRI recommends educating staff about the limitations of monitoring technology, about factors that can lead to missed events, and about implementing patient surveillance improvements. 

5. Insufficient Training of Technicians on Operating Room Technologies

Inadequate training of clinicians on OR technologies can result in errors that prolong surgery and lead to complications or additional treatments that could result in injury or death for the patient. According to the ECRI, 70% of medical-device accidents are linked to user error or bad techniques that could have been avoided with better training.

6. HIT Configurations and Facility Workflow Do Not Support Each Other

Poor alignment between the configuration of a health information technology (HIT) system and workflow increases the chances for medical errors. Problems arise when the HIT is not configured to support the processes used in a care area or if the workflows and standard operating procedures are not adjusted to accommodate the capabilities of HIT systems. 

The ECRI recommends that hospitals consider configuration issues during the HIT system selection phase, and modify and validate workflows to confirm that they align with the system’s capabilities.

7. Unsafe Injection Practices

Unsafe injection practices may lead to the transmission of blood-borne viruses, the spread of bacterial infections, and potential exposures. The ECRI identified several practices that put patients at risk, including:

  • Reusing a needle or syringe that had been used to administer medication.
  • Sharing an insulin pen among patients, even if a new needle is used.
  • Using a single-dose medication vial for multiple patients.
  • Failing to use aseptic technique when preparing, handling, and injecting medications.

8. Gamma Camera Mechanical Failures

Gamma camera failures can occur when these systems are not maintained properly, or when safety-related recalls are not addressed promptly. The ECRI says that staff should not leave patients unattended in the gamma camera scan room. They should also maintain cameras in accordance with the manufacturer's guidance, and make sure that recalls and safety notices have been acted upon.

9. Failure to Appropriately Operate Intensive Care Ventilators

Inappropriate patient ventilation can cause ventilator-induced lung injury (VILI), particularly in intensive care patients, and may lead to patient death. Lung-protective strategies (e.g., using lower tidal volumes) have been developed, and advanced ventilator modes and features are available to aid clinicians in providing safer and more-effective ventilation.

10. Misuse of USB Ports

Plugging unauthorized devices into USB ports on medical devices can cause the latter to malfunction. Direct effects on medical device operation—for example, causing a physiologic monitor to reboot—have been observed in clinical practice.

Uncontrolled access to medical-device USB ports could also lead to a security breach, putting the patient's personal data and the health care facility's systems at risk. The ECRI recommends that hospitals implement a policy on the appropriate use of USB ports on medical devices.

Sources: HealthLeaders Media; November 12, 2015; and ECRI, November 9, 2015.

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