Top 10 Health Technology Hazards for 2014

As technology in health care evolves and becomes more frequently used, there are some hazards that are becoming more prevalent, according to the ECRI Institute.

In ECRI’s annual top 10 list of health technology hazards some of the same issues have remained from the previous years.

“…all of the items on the list represent problems that can be avoided or risks that can be minimized through the careful management of technologies,” according to the report from ECRI Institute’s Health Devices Group.

The list focuses on what ECRI calls generic hazards, which result of risks that are inherent to the use of certain technologies. The group weighed such factors as:

Severity: what is the likelihood the hazard could cause serious injury or death?

Frequency: how likely is the hazard and how often does it occur?

Breadth: could consequences spread and affect a great number of people?

Insidiousness: is the problem difficult to recognize and could it lead to a cascade of errors?

Profile: could the hazard received publicity that brings on negative attention?

Preventability: could the problem be prevented or risks minimized or future occurrences reduced?

See the top 10 technology hazards.

10. Retained devices and unretrieved fragments

Surgical “never event” are occurrences that should never happen and are completely preventable during surgery—one such instance is when an item is left inside a patient, which happens roughly 39 times a week, according to a report.

Patients can then experience prolonged or additional surgery when a retained surgical item is discovered or future complications if the item leads to infection or damage.

9. Robotic surgery complications due to insufficient training

According to ECRI, there has been a rise in the number of reports describing complication patients experienced, drawing attention to the need for appropriate training and ongoing competency assessments to minimize patient risk. Right now there is no widely recognized requirements for robotic surgery training and credentialing programs.

8. Risks to pediatric patients from “adult” technologies

Unfortunately many technologies are developed with adult patients in mind and health care professionals end up using these “adult” technologies on children because they have few other options. But due to their smaller size and ongoing physiologic changes, children could suffer adverse effects.

If there are no pediatric options available, personnel need to “exercise particular care,” when using “adult” technologies on children.

7. Neglecting change management for networked devices and systems

Updates, upgrades and modifications made to one system or device can have “unintended effects on other connected devices and systems,” according to ECRI. The best way to prevent these effects is by making sure all personnel who manage or use the systems know about any alterations to the network or system beforehand.

6. Inadequate reprocessing of endoscopes and surgical equipment

Poor cleaning and disinfecting of surgical instruments and devices can lead to patient cross-contamination and the transmission of infectious agents. Some of the devices and instruments that might not get cleaned properly are flexible endoscopes, arthroscopy shoulder cannulas and surgical instrument trays, according to ECRI.

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5. Occupational radiation hazards in hybrid ORs

Operation suites that use advanced imaging capabilities expose not just patients but also OR staff to radiation risks. While radiology personnel are well versed in risks associated with ionizing radiation, they may be less knowledgeable when it comes to working in hybrid ORs on a daily basis.

4. Data integrity failures in EHRs and other health IT systems

EHR adoption has been occurring more and more rapidly in the health care industry and while they offer quality and safety benefits (as well as financial incentives), increased use means increased critical patient safety concerns.

Data can be compromised by patient/data association errors, missing or delayed data, clock synchronization errors, inappropriate use of default values, use of both paper and electronic workflows, copying and pasting old information into new reports, and basic data-entry errors, according to ECRI.

3. CT radiation exposure in pediatric patients

Pediatric patients are “inherently more sensitive” than adults are to ionizing radiation effects, according to ECRI. Exposure to ionizing radiation at a young age can increase a person’s risk of developing cancer, according to studies, and as such hospitals and practices should be sure to control the radiation dose and avoid repeat scanning.

2. Infusion pump medication errors

While infusion pumps are invaluable, they represent a large burden as hospitals may have hundreds or thousands of these devices and failure among them is not uncommon. As a result, this technology hazard remains in the second spot just like last year.

Regular training and assessment of users is necessary and infusion pump integration can provide additional protections, according to ECRI.

1. Alarm hazards

Number one in last year’s list, the prevalence of alarms can lead to fatigue, which has the potential to result in serious patient harm when health care providers are unable to respond to all alarms, when alarms become a distraction, and when they become desensitized and miss an important alarm.

According to ECRI, the Joint Commission recently cited 98 alarm-related events (60 of which results in death) over a three-and-a-half year period. As a result the commission said that certain provisions will take effect in 2014.