Top 10 List of Health Tech Hazards for 2017

Megan Brooks

November 08, 2016

Potentially deadly infusion errors that can occur with large-volume infusion pumps are the top health technology hazard that hospitals and clinicians should focus on in 2017, according to the ECRI Institute.

The annual list of technology pitfalls issued by the nonprofit research organization also includes infection risks with reusable instruments and heater-cooler devices, as well as software management oversights, and opioid monitoring challenges.

Produced each year by ECRI's Health Devices Group, the list identifies potential sources of danger that ECRI believes warrant the greatest attention for the coming year. The list is accompanied by practical strategies hospitals and health providers can take to reduce the risks.

"Technology safety can often be overlooked when hospital leaders are dealing with so many other issues," David T. Jamison, executive director of the Health Devices Group at the ECRI said in a news release. "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."

Infusion errors, this year's number 1 tech hazard, can be deadly if simple safety steps are overlooked, the group notes. Although modern large-volume infusion pumps incorporate features that reduce the risk for infusion mistakes, these safety mechanisms can't completely eliminate all potential errors, and the mechanisms themselves have been known to fail, they point out.

"The ECRI continues to receive reports and investigate incidents of uncontrolled flow of medication to the patient — a potentially fatal circumstance known as 'IV free flow' — and other infusion errors. Fortunately, as ECRI points out in its guidance document, a few simple steps can help catch use errors and component failures before patient care is affected," they say.

For example, in many of the incident reports, harm could have been averted if staff had noticed signs of physical damage to infusion pump components; made appropriate use of the roller clamp on the intravenous tubing; and checked the drip chamber beneath the medication reservoir for unexpected flow, the group says.

Taking the number 2 spot on the latest tech hazard list is inadequate cleaning of complex reusable instruments, including duodenoscopes. It's high on the list, the group notes, in part because of the severity of the infection risks and the persistence of the problem. The ECRI Institute "regularly sees reports of contaminated medical instruments being presented for use on a patient," the group notes.

"Often, we find that inattention to the cleaning steps within the reprocessing protocol is a contributing factor. Healthcare facilities should verify that comprehensive reprocessing instructions are available to staff and that all steps are consistently followed, including precleaning of the device at the point of use," they advise. Contaminated duodenoscopes made headlines in 2015, as reported by Medscape Medical News.

Coming in at number 3 is missed ventilator alarms. "Ventilators deliver life-sustaining therapy, and a missed alarm could be deadly," the group notes. Top concerns include alarm fatigue, in which staff become overwhelmed by, distracted by, or desensitized to the number of alarms that activate, and alarm notification failures, in which alarms are not effectively communicated to staff, they say.

Number 4 on this year's top hazards list is undetected opioid-induced respiratory depression. The group says "spot checks every few hours of a patient's oxygenation and ventilation are inadequate." They recommend that healthcare facilities implement measures to continuously monitor the adequacy of ventilation of these patients.

Number 5 on the list is infection risks with heater-cooler devices used in cardiothoracic surgery. Heater-cooler systems have been identified as a potential source of nontuberculous mycobacteria infections in heart surgery. The likelihood of infection during surgery is not fully understood. However, these infections can be life-threatening and have resulted in patient deaths, the group notes.

In October 2015, as reported by Medscape Medical News, the US Food and Drug Administration issued recommendations for all heater-cooler devices to help prevent and manage device contamination risks and to minimize patient exposure to heater-cooler exhaust air, which may contain aerosolized contaminated water.

Rounding out the top 10 technology hazards ECRI wants hospitals and clinicians to tackle in the coming year are:

6. Software management gaps put patients, and patient data, at risk;

7. Occupational radiation hazards in hybrid operating rooms;

8. Automated dispensing cabinet setup and use errors may cause medication mishaps;

9. Surgical stapler misuse and malfunctions; and

10. Device failures caused by cleaning products and practices.

More information about the ECRI ranking is available on the group's website.

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