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ECRI’s Top 10 Technology Hazards for 2015
Patient safety organization ECRI Institute has released its annual report examining the biggest technology hazards faced by healthcare providers--and their patients. The top 10 list for 2015 includes four holdovers from 2014 that remain serious threats, and six other hazards that now warrant inclusion. The holdovers are alarms, data integrity, inadequate reprocessing of instruments and robotic surgery. The 30-page report includes detailed explanations and mitigation recommendations for each hazard. (Photo: Fotolia)
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1. Alarm Hazards: Inadequate Alarm Configuration Policies and Practices
In ECRI Institute’s experience, alarm-related adverse events--which can involve missed alarms or unrecognized alarm conditions--can often be traced to inappropriate alarm configuration practices. Thus, we encourage healthcare facilities to examine alarm configuration policies and practices in their alarm improvement efforts, if they have not done so already.

Alarm configuration practices include, for example: determining which alarms should be enabled, selecting the alarm limits to use, and establishing the default alarm priority level. Selections are typically based on the particular needs of each care area and the acuity of the patients in that care area, along with the physiologic condition of each specific patient. (Photo: Fotolia)
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2. Incorrect or Missing Data in EHRs and Other Health IT Systems
Many care decisions are based on data in an electronic health record or other IT-based system. When functioning well, these systems provide the information clinicians need for making appropriate treatment decisions. When faults or errors exist, however, incomplete, inaccurate, or out-of-date information can end up in a patient’s record, potentially leading to incorrect treatment decisions and patient harm. What makes this problem so troubling is that the integrity of the data in health IT (HIT) systems can be compromised in a number of ways, and once errors are introduced, they can be difficult to spot and correct.
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3. Mix-Up of IV Lines Leading to Misadministration of Drugs and Solutions
In previous Top 10 Health Technology Hazard lists, we’ve addressed the role that infusion pump programming errors play in infusion-related adverse events, most notably medication errors. This year, we focus not on the pump, but on the tangle of tubing that exists when multiple IV infusions need to be administered to a single patient—a common occurrence in healthcare.

If a medication or IV solution is delivered to the wrong infusion site, or at the wrong rate, the consequences can be severe.
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4. Inadequate Reprocessing of Endoscopes and Surgical Instruments
As we were preparing this year’s list for publication, the Ebola virus had become front-page news. The highly contagious nature of this disease underscores the critical importance of the reprocessing function--that is, the cleaning and disinfection or sterilization of objects that may have become contaminated during use on a patient. Improper reprocessing procedures can place others who subsequently come in contact with the equipment at risk. (Photo: Fotolia)
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5. Ventilator Disconnections Not Caught because of Miss-set or Missed Alarms
To prevent such outcomes, ventilators incorporate sensors and alarms to warn caregivers when a disconnection occurs, whether it be the complete separation of one breathing circuit component from another or a partial disconnection that allows gases to leak from the circuit. To be effective, however, such alarms must be set to appropriate levels and must be heard when they sound. (Photo: Fotolia)
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6. Patient-Handling Device Use Errors and Device Failures
Hospitals are among the most hazardous places to work in the United States, according to a 2013 Occupational Safety and Health Administration report. And staff injuries associated with the lifting, transfer, or movement of patients are a big reason why: An OSHA article reports that, in a national survey covering approximately 1,000 hospitals, patient-handling injuries accounted for 25% of all Workers’ Compensation claims for the healthcare industry in 2011. Furthermore, patients too can be injured if patient-handling activities are not carried out effectively. (Photo: Fotolia)
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7. “Dose Creep”: Unnoticed Variations in Diagnostic Radiation Exposures
Dose creep is a pattern of radiation exposure levels (i.e., dose) being increased by clinicians over time in an attempt to achieve better image quality in diagnostic radiography. Although it is unlikely to result in immediate harm, it’s an insidious problem that can have long-term consequences and that, over time, can affect many patients. Fortunately, tools are now becoming available to help healthcare facilities combat this hazard. (Photo: Fotolia)
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8. Robotic Surgery: Complications Due to Insufficient Training
Robotic surgical systems are complex devices that change the surgical process for all involved. As with any new technology that represents a departure from previous approaches, preparation is critical to safe use. If surgeons, the rest of the surgical team, and associated staff are not sufficiently trained on how to use the robotic surgical system and how to perform a surgery under these unique conditions, adverse events can result. In fact, ECRI Institute has investigated several surgical-robot-related adverse events in which situations unique to robot-assisted surgery likely contributed to patient harm. (Photo: Fotolia)
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9. Cybersecurity: Insufficient Protections for Medical Devices and Systems
The growing trend toward the networking and connectivity of medical devices is associated with a corresponding increase in the vulnerability of these devices to malware and malicious attacks. Despite little evidence to date of direct harm to patients from the exploitation of cyber vulnerabilities, cybersecurity is nevertheless a patient safety consideration that will require increased attention in the coming years. (Photo: Fotolia)
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10. Overwhelmed Recall and Safety-Alert Management Programs
Many kinds of problems can occur with medical devices, ranging from lower-priority issues to potentially life-threatening ones. These problems can result in the issuance of recalls or safety notices from the manufacturer or safety alerts from organizations like FDA or ECRI Institute. These are intended to inform facilities about identified problems before additional incidents occur. However, alerts alone cannot protect patients from harm; healthcare facilities must respond appropriately to these alerts to avoid preventable injury. (Photo: Fotolia)
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The ECRI report, "Top 10 Health Technology Hazards for 2015," is available here. Brief registration is required.