November 9, 2016

The top 10 health technology hazards for 2017, according to ECRI

Daily Briefing

Medication infusion errors caused by large-volume infusion pumps are the top health technology hazard for 2017, according to a report released Monday by the ECRI Institute.

The ECRI Institute is a not-for-profit organization focused on improving health care quality and safety.

To create its report, ECRI's engineers, clinicians, scientists, and other patient safety analysts nominated topics. ECRI experts and outside advisory committees then selected the top 10 hazards based on factors such as severity, frequency, and preventability.

Medical devices can be deadly—but regulations are lax

ECRI's top 10 technology hazards for 2017 were:

  1. Infusion errors, which can be deadly if simple safety steps are overlooked;
  2. Inadequate cleaning of complex reusable instruments, which can lead to infections;
  3. Missed ventilator alarms, which can lead to patient harm;
  4. Undetected opioid-induced respiratory depression;
  5. Infection risks with heater-cooler devices used in cardiothoracic surgery;
  6. Software management gaps that put patients, and patient data, at risk;
  7. Occupational radiation hazards in hybrid ORs;
  8. Automated dispensing cabinet setup and use errors, which may cause medication mishaps;
  9. Surgical stapler misuse and malfunctions; and
  10. Device failures caused by cleaning products and practices.

Medication pumps

The top hazard, medication infusion pumps, can be particularly dangerous when malfunctions lead to the release of too much medication into a patient. "Although today's pumps incorporate features that reduce the risks of infusion errors, these safety mechanisms cannot eliminate all potential errors, and the mechanisms themselves have been known to fail," ECRI said in a statement.

However, ECRI said that "a few simple steps" can help guard against errors, such as:

  • Training staff to look for equipment damage;
  • Making "appropriate use of the roller clamp" on IV tubing; and
  • Checking drip chambers for unexpected flow.

Cleaning reusable medical instruments

The second-ranked hazard relates to reusable medical instruments, which have been a high-profile source of infections in recent years.

According to ECRI, "complex, reusable instruments such as endoscopes, cannulated drills, and arthroscopic shavers," are particularly hard to clean and prone to contamination. Staff should be careful to follow cleaning protocols provided by device manufacturers and to preclean devices "at the point of use," the report advised. And provider organizations should pressure manufacturers to provide detailed, up-to-date guidance about how to properly clean medical devices. 

Scott Lucas, ECRI's associate director of accident and forensic investigation, also said that cleaning teams need to have adequate time to reprocess medical devices. ECRI recommended that health systems create multidepartment, multidisciplinary committees tasked with ensuring devices are properly cleaned.

"It's not just [the sterile processing department] or clinicians," Lucas said. "This really is a systemic challenge."

Focusing on technology safety

David Jamison, executive director of the health devices group at ECRI, said the broader message of the report was that technology safety must be a high-priority issue for health care providers. "Technology safety can often be overlooked when hospital leaders are dealing with so many other issues," he warned (Monegain, Healthcare IT News, 11/7; Rubenfire, Modern Healthcare, 11/7; ECRI Institute release, 11/7).

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