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ECRI’s Top 10 Health Technology Hazards for 2016

Flexible medical endoscopeTechnology: Hospitals need it to stay competitive, doctors need it to improve patient care with greater precision and safety, and staff need it to enhance workflow. These are all pluses. But, as usual, with the pluses come minuses. That’s why ECRI released its Top 10 Health Technology Hazards for 2016. 

The nonprofit organization is dedicated to improving patient care and produces this list each year to help hospitals identify potential dangers to patient safety influenced by technology. While the issues on the list aren’t always the ones that happen the most or have the most severe consequences, they’re the ones, which after in-depth analysis, the institute believes require immediate attention.

The good news is, every item on the list can be avoided or minimized.

So without further ado, here’s ECRI’s Top 10 Health Technology Hazards for 2016:

#1 Inadequate cleaning of flexible endoscopes

This issue has risen to the top of the list because inadequate cleaning and disinfection of clinical instruments can spread deadly pathogens to subsequent patients.

Earlier this year, several patients fell ill due to an outbreak of carbapenem-resistant Enterobacteriaceae (CRE) bacteria that was traced to the scopes used during their procedures.

Due to their complex design and long, narrow channels, flexible endoscopes in general, and specifically duodenoscopes, can be challenging to clean effectively. Pieces of biologic debris can remain in the scopes after cleaning, making sterilization or disinfecting ineffective.

That’s why hospitals have to emphasize to their reprocessing staff that adherence to all cleaning steps in the process must be followed 100% of the time.

#2 Missed alarms

Alarm fatigue held the No.1 spot for the past four years. While it now sits in the No. 2 position, it’s still a major problem that can cause serious harm to patients.

There are three ways alarms can be missed and harm patients:

  • The alarm condition is not detected by the medical device
  • The condition is detected, but isn’t communicated to a medical professional, and
  • The condition is detected and communicated to a medical professional, but it’s not appropriately addressed.

Thousands of alarms go off every day in hospitals, and staff can become immune to them. It’s vital for facilities to have a comprehensive alarm management program in place that’s supported at all levels of management.

#3 Failure to monitor postop patients for opioid-induced respiratory depression

Drug-induced respiratory depression can lead to brain injury or death, in sick and patients who are otherwise healthy.

Intermittent checks of oxygenation and ventilation every few hours aren’t good enough. Hospital leaders need to implement the recommendation from the Anesthesia Patient Safety Foundation (APSF) and the Joint Commission.

#4 Inadequate surveillance of monitored patients in a telemetry setting

This can lead to unrecognized critical events which can harm patients and even lead to death.

For example, monitoring system can’t be relied upon to detect all potentially lethal arrhythmias. This is especially true now that more facilities are using telemetry monitoring with sicker patients than in the past.

The key is to educate appropriate staff about the limitation of the monitoring technology and factors that could lead to missed events. Hospitals should also set up patient surveillance protocols and make sure they’re followed.

#5 Insufficient training on operating room (OR) technologies

According to ECRI, approximately 70% of accidents involving a medical device can be attributed to user error or poor technique. And many of these events could have been prevented with better device training.

Hospital leaders need to make sure protocols are in place to train any and all OR team members.

#6 HIT configurations and facility workflow don’t align

Missed information, the inability to find information on the system, input errors, using workarounds, and using default values instead of desired values for dosing, times or orders; all of these things increase the opportunity for errors that could harm patients.

That’s why it’s so important for facilities to know what they want and need during the HIT system selection process. Involving staff at all levels is important to validate workflow processes that need to align with the system’s capabilities.

#7 Unsafe injection practices

Transmission of bloodborne viruses and the spread of bacterial infections are the results of unsafe injection practices.

These practices could include reusing syringes, sharing insulin pens among patients, using single doses medication vials for multiple patients, and failing to use aseptic techniques when preparing, handling and injecting medication.

Not only do these practices jeopardize patients’ health, they also jeopardize your facility. They could damage a facility’s reputation and could even result in criminal prosecution and penalties.

Again, protocols have to be implemented, and they must be supported by hospital leaders and followed by all staff.

#8 Gamma camera mechanical failures

ECRI and the FDA have received a number of reports about mechanical failures involving gamma cameras that have seriously injured patients, even killing a patient in one instance.

These cameras are composed of heavy moving parts that can cause major harm.

It’s vital for staff to maintain, service and inspect the camera in accordance with the manufacturer’s specifications. They also need to stay current and act on all recalls and safety notices, and never leave patients unattended in the scan room.

#9 Improper operation of intensive care ventilators

In the intensive care unit, improper use of ventilators can cause ventilator-induced lung injury and even death.

This happens due to a lack of continuing education on best practices, insufficient understanding of complex ventilator functionality and inconsistent terminology among ventilator manufacturers that causes confusion among clinicians.

Make sure all appropriate staff involved with mechanical ventilation know how to use these devices accurately and provide continuing training opportunities.

#10 Misuse of USB ports

Using unauthorized devices and plugging them into USB ports on medical equipment can cause the equipment to malfunction. These malfunctions could be anything from shutting down the machine to changing device settings to failure to trigger alarms.

It can also lead to security breaches by compromising patients’ protected health information.

Policies need to be developed and implemented on proper use of USB ports on medical devices.

 

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