Ever-evolving technology has provided new opportunities to improve patient care. However, unless they are properly used or monitored, these same technologies can also cause patients harm.
Ever-evolving technology has provided new opportunities to improve patient care. However, unless they are properly used or monitored, these same technologies helping patients can also cause harm.
ECRI Institute has released its annual top 10 list of potential health technology hazards that warrant particular attention in 2013. The list includes hazards ECRI has witnessed occurring regularly as well as problems that could become more prevalent.
Illustrating how common health information technology (HIT) is becoming, three of the top 10 are associated with HIT.
Factors considered to rank each topic were: potential for harm; frequency and likelihood; breadth of hazard; insidiousness; and profile.
10. Surgical fires
Anesthesia Patient Safety Foundation/FDA.gov
This issue has been on multiple past top 10 lists from ECRI because they are high-impact with potentially devastating consequences and they continue to occur. Thankfully, they aren’t common.
“Fires that ignite in, on, or around a patient during surgery are extremely rare, occurring in only a minuscule percentage of the millions of surgical cases performed each year,” ECRI writes.
9. Caregiver distractions from mobile devices
Mobile devices in the health field have been given a lot of scrutiny to determine if private patient information can be exposed, but real harm can come to patients if caregivers are distracted by their devices and provide substandard care.
8. Inadequate reprocessing of endoscopic devices and surgical instruments
In past lists ECRI has note the cross-contamination hazards that can result when flexible endoscopes are not properly processed.
“At minimum, endoscope reprocessing problems (when discovered) can create anxiety when patients are told they may have been exposed to a contaminated endoscope,” ECRI writes. “At worst, they can lead to life-threatening infections.”
7. Inattention to the needs of pediatric patients when using “adult” technologies
Often a technology designed with adult patients in mind is used on children when no alternatives of devices tailored exclusively for the pediatric population exists. For instance, radiation dose settings for adults are usually inappropriate for children.
6. Air embolism hazards
Clinicians are generally aware of the risks of air embolism during certain medical and surgical procedures so this issue wasn’t on the list last year. Unfortunately, ECRI still receives reports of fatal incidents. From June 2004 to December 2011 there were 34 reports of serious events resulting in harm, seven of which resulted in permanent harm and six deaths.
5. Interoperability failures with medical devices and HIT systems
The potential to reduce errors and improve patient safety is possible with proper integration, but it can be difficult to achieve and result in patient harm if not done effectively.
“Despite the challenges associated with integrating medical devices and systems, health care facilities ultimately should be moving in that direction, though being mindful of both the benefits and risks,” ECRI writes.
4. Patient/data mismatches in HIT systems
A specific type of interoperability failure, this issue can render the skills of a physician and staff members meaningless. These mix-ups have occurred in traditional paper-based systems; however, in cases of HIT systems, it might not be readily apparent if the error was a result of human error or a system design flaw.
3. Unnecessary exposures and radiation burns
Acute reactions to excessive radiation exposure happen only in extreme cases; however, the more pressing concern is that excessive exposure will increase a patient’s risk of developing cancer.
2. Medication administration errors using infusion pumps
Up a spot from last year, the FDA receives more adverse incident reports regarding infusion devices than any other medical technology, according to ECRI. From 2005 to 2009 the FDA received reports of 710 deaths associated with infusion devices.
1. Alarm hazards
Number one for two years in a row, alarm hazards are a “high-impact, high-profile patient safety concern,” according to ECRI. The number of alarms on medical devices can overwhelm caregivers trying to respond to them or cause them to become desensitized and place patients at risk.