ECRI Institute picks information security threats as the biggest risk for the New Year.
10 top health technology hazards for 2018
Research firm ECRI Institute has issued its top health technology hazards list for 2018, identifying potential sources of danger that warrant high attention in the New Year. “This list reflects our judgement about which risks should receive priority now” from healthcare providers, the organization says.
1. Ransomware and other malware threats
Malware attacks impact care delivery by making IT systems unusable, preventing access to patient records and affecting the functionality of networked medical devices. Attacks also can disable third-party services, disrupt the supply chain and hinder care delivery.
2. Contaminated flexible endoscopes
The process for cleaning these devices is largely manual and technique-dependent. If biologic debris and other foreign matter is not cleaned from the endoscope first, residual soil can harden, making subsequent disinfection ineffective. Instrument storage after reprocessing is critically important. Moisture trapped in the channels of an endoscope can promote proliferation of any microbes not eradicated by reprocessing.
3. Unclean bed and stretcher mattresses
Reported incidents include patients lying on an apparently clean bed or stretcher when blood from a previous patient oozed out of the support surface onto the patient. A bed or stretcher’s support surface consists of a mattress along with a mattress cover that prevents the ingress of body fluids and other contaminants into the mattress. The mattress cover is cleaned and disinfected, but the mattress is not.
4. Missed alarms from inappropriately configured devices and systems
Secondary alarm notification systems are software products that send alarms and other relevant alerts from a medical device or IT system to a clinician’s smartphone or other device, but configuration or management problems can lead to alarm delivery delays or failures.
5. Improper cleaning of devices or equipment
Unapproved cleaning agents can cause deterioration of a device’s nonmetallic parts, which can lead to weakening or breakage of parts. This also can lead to failure of device electronics or power supplies because of component damage or fluid intrusion.
6. Unholstered electrosurgical active electrodes
Active electrode pencils not safely holstered between activations can lead to burns or fires if inadvertently activated. Injury has occurred when OR staff placed the active-electrode pencil on or near the patient between activations, rather an in the holster.
7. Radiation exposure due to mistakes in digital imaging
Computed tomography, angiography, nuclear medicine and other imaging tools have inherent risks, particularly exposure to ionizing radiation from individual or multiple exposures, increasing risk of cancer. Further, excessive doses during a procedure can cause radiation burns.
8. Workarounds with bar-code medication administration systems
Improper practices include administering medications before using the bar code scanner, scanning patient bar codes from a list of stickers on a clipboard rather than the patient wristband, and preparing medications for more than one patient at a time.
9. Flaws in medical device networking
Examples of these types of errors include lab results being delivered from a lab information system to the electronic health record with reference ranges but no lab values, leading to a delay in patient diagnosis and treatment; or only partial information is being forwarded from a ventilator to the physiologic patient monitor; or data from a fetal monitor is not correctly displayed on the workstation at the nurse’s station, possibly delaying response to a critical change in the patient’s condition.
10. Slow adoption of safer enteral feeding connectors
Enteral feeding tubing can inadvertently be connected to patient lines intended for other purposes, which can be fatal. In one case, enteral nutrition was delivered into a patient’s lungs when feeding tubing was misconnected to a ventilator suction catheter. In another incident, nutrition was delivered through an IV line directly into the bloodstream of a pregnant woman. Neither patient survived.