ECRI Institute, a non-profit research
organization, recently released its annual Top 10 List of Health Technology Hazards
for 2018. The purpose of this report is to inform healthcare facilities about the
important safety issues involving the use of health technology and bring
attention to potential sources of danger. The full report includes practical
strategies hospitals and healthcare providers can take to help reduce patient
safety risks.
The following is the list of top Health IT
Safety Hazards for 2018:
- Ransomware and
Cybersecurity Threats Can Put Patients at Risk- Ransomware
has been one of the most globally talked about issues facing healthcare
organizations today. This malware can disrupt healthcare delivery operations
and the delivery of care, placing patients in danger. Protection against
malware attacks requires an organization to take a proactive approach through
senior management, clinical engineering, IT professionals, and other key
individuals.
- Endoscope Reprocessing
Failures Expose Patients to Infection Risk- Failure
to consistently and effectively reprocess (clean and sterilize) flexible
endoscopes can lead to the spread of deadly infections. To achieve more
reliable and effective endoscope reprocessing, ECRI Institute recommends that healthcare
facilities: (1) establish processes for assessing the quality of the cleaning
step such as, through magnification-aided visual inspections and the use of
biochemical testing (2) implement measures to dry endoscope channels after
reprocessing.
- Mattresses and Covers
Infected with Contaminants May Put Staff and Patients at Risk- Bed and stretcher mattresses often remain contaminated after they
have been cleaned, which puts patients and staff at risk of exposure. To safeguard against this risk, companies that
sell or rent mattress covers must recommend cleaning and disinfecting materials
that will remove the contaminants without compromising the cover’s integrity.
Healthcare facilities should also use appropriate materials and procedures for
cleaning and disinfecting mattress covers. It is also necessary to regularly
inspect mattresses and mattress covers for signs of damage or contamination.
- Missed Alarms May Result
from Inappropriately Configured Secondary Notification Devices and Systems- Secondary alarm notification systems send alarms and other relevant
alerts from a medical device or IT system to a clinician’s smartphone or other
communication device. They are intended to send timely notifications to the appropriate
clinician. However, sometimes configuration or management problems with the
systems can lead to alarm delivery delays or failures. This can lead to missed
alarm conditions, delayed care, and avoidable patient harm. Avoiding such
problems requires care during system configuration, verification and validation
during implementation, and assessments of system integrity periodically during
use.
- Improper Cleaning May
Cause Device Malfunctions, Equipment Failures, and Potential for Patient Injury-
Incompatible
cleaning agents or unapproved cleaning methods used on medical devices and
other equipment can result in device malfunctions and safety issues, that lead compromised
patient care. The need to stock and use multiple cleaning products, along with
the requirement to familiarize staff with device-specific cleaning methods, is
a significant burden for hospitals. Nevertheless, the risk of harm to patients
and staff, and the substantial costs to replace damaged devices, can sometimes outweighs
the challenge of implementing safe and correct cleaning.
- Unholstered
Electrosurgical Active Electrodes Can Lead to Patient Burns- Electrosurgical unit (ESU) active-electrode pencils that are not
safely holstered between activations can lead to burns or fires if the ESU is
inadvertently activated. Proper and consistent use of the safety holsters that
are typically supplied with active-electrode pencils can prevent such
incidents. In fact, ECRI Institute’s data shows, the added costs associated
with holster use are minimal.
- Inadequate Use of Digital Imaging
Tools, May Lead to Unnecessary Radiation Exposure-
Imaging technologies play a vital role in modern medicine, but have inherent
risks that must be managed. Exposure to high doses of ionizing radiation, can
increase a patient’s long-term risk of developing cancer. While extremely high
doses during an individual procedure can cause radiation burns. Imaging
departments and facilities should investigate dose-control strategies and provide
users with the training and support they need to gain confidence using newer
tools and techniques.
- Improper Practices Using Bar-Coded
Medication Administration Systems- Bar-coded
medication administration (BCMA) systems help clinicians verify at the point of
care that the medications to be administered match provider orders. Used the
right way, these systems can prevent dangerous medication errors. Used
incorrectly, BCMA’s safety advantages can be completely negated. Improper
practices include administering medications before using the bar-code scanner,
scanning patient bar codes from a list of stickers on a clipboard instead of
from the patient wristband, and preparing medications for more than one patient
at a time. Maximizing the safety benefits of BCMA requires minimizing the
circumstances that can lead to improper use. To do this, give careful thought
to system implementation, verify that staff understand the importance of
performing the multistep workflow correctly, and maintain the system so that
all the component devices and systems function properly.
- Flaws in Medical Device Networking
Can Lead to Delayed or Inappropriate Care- Inattention
to best practices for implementing networked medical devices and information
systems can lead to incorrect or incomplete data transfers and other data
communication errors. Such errors can delay diagnosis or treatment or prompt a
misdiagnosis, affecting patient safety. With more and more medical devices and
information systems being connected through hardwired or wireless networks, it
has become increasingly important for healthcare facilities to assess, approve,
and implement changes to these networked medical devices and information
systems in a controlled manner.
- Slow Adoption of Safer Enteral
Feeding Connectors Can Leave Patients at Risk-
Enteral feeding tubing can be inadvertently connected to patient lines intended
for other purposes, sometimes with fatal consequences. A newly available,
standards-based connector design for enteral feeding systems—known by its
trademarked name, ENFit—can help prevent such misconnections. To date,
healthcare facilities have been slow to adopt enteral devices with ENFit
connectors, primarily due to concerns over the availability of components
bearing the new connectors. However, this situation has improved, and a
successful transition is now possible. ECRI Institute and other organizations
recommend that healthcare providers throughout the world transition to enteral
devices with ENFit connectors as soon as practicable
More information about the ECRI ranking is
available on the group's website. https://www.ecri.org/Pages/2018-Hazards.aspx