Infusion Errors Head ECRI Institute's List Of Health Tech Hazards For 2017
By Christine Kern, contributing writer
List identifies greatest potential dangers for healthcare and provides strategies to reduce risks.
Infusion errors top ECRI Institute’s list of the most dangerous and largely preventable safety hazards related to health technology for 2017. The list is compiled on an annual basis to point out potential safety issues that warrant attention in the coming year. Although new technology has incorporated features to reduce the risks of infusion errors, ECRI says the safety mechanisms cannot eliminate all potential errors, and points to incidents of mechanism failures.
In the number two spot, ECRI lists inadequate cleaning of complex reusable instruments like duodenoscopes which can lead to infection with the severity of the infection risk and persistence of the problem are factors in its inclusion. Olympus snagged headlines last year when investigations revealed high incidents of infection with its scopes due to a design flaw that kept them from being properly cleaned. Olympus subsequently pledged to recall and redesign all affected scope to rectify the problem.
“Technology safety can often be overlooked when hospital leaders are dealing with so many other issues,” explained David T. Jamison, executive director, health devices group, ECRI Institute. “As an independent medical device testing laboratory and investigator of technology-related incidents, we know what can go wrong and what steps hospitals can take to reduce patient harm related to specific technologies and processes.”
- missed ventilator alarms
- undetected opioid-induced respiratory depression
- infection risks with heater-cooler devices used in cardiothoracic surgery
- software management gaps, which put patients and patient data at risk
- occupational radiation hazards in hybrid operating rooms
- automated dispensing cabinet setup and use errors
- surgical stapler misuse and malfunctions
- device failures caused by cleaning products and practices
ECRI based the ranking on the severity of infection risks and the problem’s persistence. Issues are selected based on factors such as severity, frequency, scope of consequences and preventability.
The report also includes a section listing resources to address each of the ten hazards. As ECRI asserts, “The safe use of health technology — from basic infusion pumps to large, complex imaging systems — requires identifying possible sources of danger or difficulty with those technologies and taking steps to minimize the likelihood that adverse events will occur.” This list is designed to help healthcare facilities achieve that.