Slideshow Top 10 Health Technology Hazards for 2016

  • November 09 2015, 10:33pm EST
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Top 10 Health Technology Hazards for 2016 from ECRI Institute

In an annual list of top technology hazards associated with medical devices and information systems, patient safety organization ECRI Institute highlights dangers it believes warrant the greatest attention in 2016. “The list does not enumerate the most frequently reported problems or the ones associated with the most severe consequences--although we do consider such information in our analysis,” the organization explains. “Rather, the list reflects our judgment about which risks should receive priority now.”

The list gives a glimpse of the scope of technological complexity, including health IT, with which hospital staff must contend daily. (Photo: Fotolia)

1. Inadequate cleaning of flexible Endoscopes before Disinfection can Spread Deadly Pathogens

“A key aspect of effective reprocessing is cleaning biologic debris and other foreign material from instruments before the disinfection or sterilization step. If this pre-cleaning is not carried out effectively, the disinfection or sterilization step may not be effective.” ECRI reminds providers that some endoscopes, especially duodenoscopes, are difficult to clean because of their design and long narrow channels.

“A series of fatal carbapenem-resistant Enterobacteriaceae infections that attracted a lot of attention in 2014 and 2015 illustrates this concern: The deaths were associated with the use of duodenoscopes that had not been successfully disinfected between uses. Facilities need to emphasize to their reprocessing staff that inattention to the cleaning steps within the reprocessing protocol can lead to deadly infections.” (Photo: Fotolia)

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2. Missed Alarms can Have Fatal Consequences

“Patients are at risk when an alarm condition is not detected by a medical device such as physiologic monitor, ventilator or infusion pump; when a condition is detected but not successfully communicated to a staff member who can respond; or when the condition is communicated to clinical staff but not appropriately addressed—whether because staff fail to notice the alarm, choose to ignore an alarm that warrants a response, or otherwise respond incorrectly.”

3. Failure to Effectively Monitor Postoperative Patients for Opioid-Induced Respiratory Depression Can Lead to Brain Injury or Death

Patients may receive another drug that also has a sedating effect, or may have undiagnosed or diagnosed conditions such as morbid obesity or sleep apnea that predispose them to respiratory compromise, or a medication error may delivery more medication than intended. “Intermittent spot checks of oxygenation and ventilation every few hours are inadequate for reliably detecting opioid-induced respiratory depression,” according to ECRI. (Photo: Fotolia)

4. Inadequate Surveillance of Monitored Patients in a Telemetry Setting May Put Patients at Risk

Contributing factors include incorrect assumptions that monitoring systems can reliably detect all potentially lethal arrhythmias, a trend to use telemetry monitoring with sicker patients than in the past and in care areas where patients are not as closely supervised, and display of monitoring information solely at the central station.

“Alleviating this problem entails educating appropriate personnel about the limitations of monitoring technology and the factors that could lead to missed events, as well as implementing measures to improve patient surveillance,” ECRI says. (Photo: Fotolia)

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5. Insufficient Training of Clinicians on Operating Room Technologies Puts Patients at Increased Risk of Harm

Errors can result if training is insufficient and does not provider an assurance of competency, if training does not include all relevant team members, or if training is not completed by all relevant team members before they use a device in clinical practice. “ECRI Institute estimates that approximately 70 percent of accidents involving a medical device can be attributed to user error or the technique of use.” (Photo: Fotolia)

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

This leads to missed information or the ability to find needed information in the HIT system, mistaken application of default values—for dosing, time or orders—instead of the desired values, input errors, and the use of workarounds. “Any of the above problems can result in patient harm due to delayed, incorrect or undelivered therapies,” ECRI advises. (Photo: Fotolia)

7. Unsafe Injection Practices Expose Patients to Infectious Agents

A long list of such practices include reusing needles or syringes, sharing an insulin pen among patients, using a single-dose medication vial for multiple patients, and failure to use aseptic technique when preparing, handling and injecting medications. Cross-contamination from unsafe injection practices can lead to disease transmission, damage to the organization’s reputation, finances and accreditation; and criminal prosecution. (Photo: Fotolia)

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8. Gamma Camera Mechanical Failures Can Lead to Serious Injury or Death

“Gamma cameras incorporate heavy, moving components that can cause significant harm if they rotate into or fall into a patient or staff member. ECRI Institute and FDA have received multiple reports of mechanical failures involving gamma cameras that have caused serious--and in one case fatal--injuries.” More than 40 gamma camera recalls filed in a recent two-year period demonstrate the risks, according to ECRI. (Photo: Fotolia)

9. Failure to Appropriately Operate Intensive Care Ventilators Can Result in Preventable Ventilator-Induced Lung Injuries

“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,” ECRI says. However, the techniques may not be used to full advantage and best practices and device capabilities may not be assessed and adopted when warranted. There is a lack of continuing education of best practices, insufficient understanding of complex ventilator functionality and inconsistent terminology among ventilator manufacturers, which lead to potential confusion for practitioners. (Photo: Fotolia)

10. Misuse of USB Ports Can Cause Medical Devices to Malfunction

“Plugging unauthorized devices or accessories into USB ports on medical devices can cause the devices to malfunction,” according to ECRI. “Direct effects on medical device operation--for example, causing a physiologic monitor to reboot--have been observed in clinical practice.”
Other problems can include the device shutting down and the patient not receiving therapy, device settings being changed or performance is otherwise compromised, and a patient monitor ceases to monitor a patient or fails to alarm for problems that require attention. (Photo: Fotolia)