Top 10 health technology hazards for 2017

Published
  • November 22 2016, 4:00am EST

Use of advanced tech in healthcare heightens risks to patients

Patient safety organization ECRI Institute has released its annual list of the potentially dangerous health technologies, focusing on issues that warrant attention in 2017.

“This list focuses on what we call generic hazards—problems that result from the risks inherent in the use of certain types or combinations of medical technologies,” according to the firm. The ECRI list does not discuss risks or problems that pertain to specific models or suppliers. Factors ECRI weighed to determine inclusion in the list include severity, frequency, breadth, insidiousness, profile and preventability.

1. Infusion errors can be deadly if simple safety steps are overlooked

Errors include pump or administration set failures, staff unknowingly defeating a safety mechanism, or incorrect fusion programming, all of which can lead to the uncontrolled flow of medication. Staff should look for signs of physical damage to infusion pump components, make appropriate use of the roller clamp on the IV tubing, and check the drip chamber beneath the medication reservoir for unexpected flow.

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2. Inadequate cleaning of complex reusable instruments can lead to infections

Duodenoscopes, endoscopes, cannulated drills and arthroscopic shavers are of particular concern, according to ECRI. “They can be difficult to clean, and then disinfect or sterilize (i.e., reprocess) between uses, and the presence of any lingering contamination can be difficult to detect.” Comprehensive reprocessing instructions should be made available to staff with all steps consistently followed.

3. Missed ventilator alarms can lead to patient harm

Alarm fatigue continues to be a concern, with staff overwhelmed by, distracted by or desensitized to the number of alarms that activate. Alarm notification failures also might not be communicated to staff.

A particular challenge with ventilators is that collecting and analyzing data can be difficult, “making it harder for hospitals to identify where their vulnerabilities are,” ECRI notes. “And the options for supplementing a ventilator’s alarms so the alarm can be noticed outside the patient’s room are limited.” Hospitals need to find new methods for studying the problem and addressing ventilator alarm responses.

4. Undetected opioid-induced respiratory depression

Spot-checking every few hours of a patient’s oxygenation and ventilation are inadequate, ECRI contends. Even if otherwise healthy, patients can be at risk if receiving another drug that also has a sedating effect, or they have diagnosed or undiagnosed sleep apnea or other conditions that predispose them to respiratory compromise, or they receive more medication than intended. Facilities should continuously monitor the adequacy of ventilation of these patients.

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5. Infection risks with heater-cooler devices used in cardiothoracic surgery

These devices are used to “warm or cool the patient by extracorporeal heat exchange with the patient’s blood during heart-lung bypass procedures,” ECRI says. “These devices circulate warm or cold water through a closed circuit. Water in the circuit is not intended to come into direct contact with the patient or the patient’s circulating blood. However, aerosolized water carried by air from the exhaust vents of contaminated heater-coolers has been suggested as a cause of nontuberculous mycobacteria infections.”

6. Software management gaps put patients and patient data at risk

“Inadequate medical device software management can delay a facility’s responses to safety alerts, allow cyber security violations to be exploited and impact patient safety,” ECRI asserts. Providers should verify the computerized maintenance management system can effectively track software versions for medical devices and systems, and have procedures for keeping version information current and complete.

7. Occupational radiation hazards in hybrid operating rooms

“Clinicians working in hybrid ORs—operating suites that include built-in X-ray imaging systems—are at risk of unnecessary occupational exposures to ionizing radiation if appropriate precautions are not consistently followed,” ECRI cautions. These clinicians should receive OR-specific radiation exposure training, along with tools and methods to minimize exposures.

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8. Automated dispensing cabinet setup and use errors may cause medication mishaps

“Medication errors and near misses associated with automated dispensing cabinets (ADCs) have been traced to insufficient planning when setting up medication drawers, as well as errors made when stocking them,” says ECRI. These errors include the wrong drug or dose in an ADC pocket, availability of high-alert drugs in an unsecured area of a cabinet and unavailability of needed drugs.

9. Surgical stapler misuse and malfunctions

Common problems include misfiring or difficulty in firing, misapplied staples, unusual sounds that could indicate a malfunctioning mechanism, and tissue becoming jammed in the mechanism. Users should be familiar with the device, select the appropriate staple size and be alert to signs that the device is not properly working.

10. Device failures caused by cleaning products and practices

Cleaning agents or practices incompatible with materials in a medical device can cause malfunctions, possibly with no visible signs. “The use of improper cleaning practices can damage seals, degrade lubricants and cause fluid intrusion,” according to ECRI. Hospitals should stock a variety of cleaning products and familiarize staff on which products are compatible with which devices. The full report is available here.