Top 10 list of health tech concerns

December 17, 2015

The non-profit ECRI Institute has ranked the top health technology hazards in 2015 to highlight the often overlooked risks that medical technology poses to patient care.

The healthcare industry aims to heal the sick and promote health, but there are dangers lurking.

The non-profit ECRI Institute ranks the top health technology hazards each year to highlight the often overlooked risks that medical technology poses to patient care.

The perennial list-topper of safety risks related to missed alarms has been replaced with a new tech concern.

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In addition to risks for patient safety, health technology hazards can also hurt the delicate budgets of health systems, as patient injuries and infections deemed to be the fault of the healthcare facility are typically not covered by payers.

The following top 10 items were identified by ECRI using a team of engineers, scientists, nurses, physicians, and safety analysts. The full 2016 Top 10 Health Technology Hazards Executive Brief also includes recommendations on interventions and safety measures to avoid adverse events related to these technology hazards.

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10. USB blunders

Universal Series Bus (USB) devices are not as universal as their name would imply when it comes to medical devices. Plugging unauthorized devices into USB ports on medical devices could lead to device malfunction, including device shutdown leading to a lack of therapeutic benefit, changes to device settings, or failure to monitor patient changes. Uncontrolled USB access to medical devices could also lead to security breaches, ECRI says.

Hospitals should clearly outline policies on appropriate use of USB ports on medical devices, ECRI says.

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9. Improper ventilator operation

Lung-protective strategies have been developed to prevent ventilator-induced lung injury (VILI), but ECRI says these guidelines are often not used to their full advantage.

Particularly in intensive care unit patients, best practices are needed to ensure patient safety, and a lack of continuing education can lead to VILI or even death, says ECRI.

Hospitals should make sure that all staff involved with using ventilators understand their function, use, and the best practices associated with operation of the devices.

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8. Gamma camera mechanical failure

The heavy, moving components of gamma cameras can result in significant injury to patients and staff members if they rotate or fall onto someone. The ECRI Institute says it and the US Food and Drug Administration (FDA) have recorded multiple reports of such mechanical failures, including 1 event that resulted in death.

More than 40 safety recalls have been filed with FDA over gamma cameras over a 2-year period, and failures are typically attributed to improper maintenance or failure to address recalls and safety warnings.

The ECRI Institute advises hospital not to leave patients unattended in gamma camera scan rooms, and to service and inspect the cameras according to the manufacturer’s guidelines.

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7. Unsafe injections

There are a lot of ways to jeopardize patient safety when it comes to injections. The ECRI Institute says incidents that can lead to the transmission of bloodborne pathogens, bacterial infections, and other exposures happen “far too often.”

Some risky practices include re-using needles or syringes, sharing insulin pens even when a new needle is used, using single-dose medication vials for multiple patients, and other practices that could lead to cross-contamination.

The ECRI Institute says in addition to putting patients at risk of disease transmission and even death, unsafe injections can damage a hospitals reputation, financial health, and accreditation status, as well as lead to criminal charges.

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6. Incongruent workflows

When health information technology (HIT) systems and a facility’s workflow fail to work seamlessly together, patients can suffer. Health information technology should support the workflow of the unit where it is used and care should be taken to ensure all data needed for patient care is accessible. Workflow problems can also lead to dosing, time, and order errors resulting from inaccurate default values or input errors, ECRI says.

Configuration should be reviewed at the time an HIT system is selected, and customized to align with workflow needs, ECRI says.

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5. Training shortfalls in the operating room

Accuracy is key in the operating room, but errors that result in injury, additional treatment, prolonged surgery, or even injury and death result too often when clinicians aren’t properly trained on the tools used in this acute setting.

The ECRI Institute estimates that 70% of all medical devices accidents occur as a result of improper use stemming from poor clinician training. Hospitals should be vigilant in making sure that clinicians have sufficient demonstrated skill using operating room technologies, including all staff members that will be involved in the use. Competencies should be demonstrated on operating room tools and procedures before use in clinical practice, cautions ECRI.

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4. Inadequate telemetry surveillance

Telemetry monitoring can help healthcare providers keep a close eye on some of their sicker patients, but ECRI says monitoring systems can’t detect every lethal arrhythmia and staff aren’t always watching monitors closely enough to detect subtle but serious rhythm changes.

Ensuring appropriate surveillance is provided for telemetry patients, hospitals should work on educating healthcare providers on the limitations of their equipment, and be sure resources are available to provide adequate surveillance.

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3. Failure to recognize post-operative opioid-induced respiratory depression

One of the top concerns of opioid medications is the effect it has on a patient’s respiratory rate. Respirations can become slower and more shallow, leading to inadequate oxygenation that could cause brain injury or death. Patients are particularly at risk if they are receiving another sedating medication, if they have comorbidities that further stress their respiratory system, or if a medication error is made that delivers an improper concentration.

The ECRI Institutes recommends hospitals institute intermittent spot checks of respirations and oxygenation, and implement recommendations from the Anesthesia Patient Safety Foundation and the Joint Commission.

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2. Missed alarms

Alarms are a common sound on every healthcare unit-from bed alarms to alarms on infusion units and monitoring devices. Too often, though, alarms are missed through alarm fatigue by staff, improperly functioning devices, or failure of staff to respond properly to the alarm. The problem of missed alarms was for years ranked by ECRI as the top health technology hazard, and resulted in the creation of a new patient safety goal by The Joint Commission in 2014. In 2014, The Joint Commission required hospitals to identify and prioritize the most important alarms in their facility, and by January 2016, hospitals will have to implement specific policies and procedures to address those alarms.

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1. Dirty instruments

Effective reprocessing of contaminated medical instruments is critical to preventing the spread of dangerous, if not fatal, microorganisms. A sometimes overlooked step in this process is pre-cleaning the instruments to move biological and foreign debris, according to ECRI. Without this step, subsequent disinfection and sterilization may not be effective, the institute says. Specifically, flexible endoscopes and duodenoscopes-whose long-narrow design can make cleaning difficult, have gained attention after a series of Carbapenem-resistant Enterobacteriaceae (CRE) infections from contaminated duodenoscopes resulted in fatalities. This issue gained attention after a series of fatal CRE outbreaks in 2014 and 2015, according to ECRI.

The ECRI Institute recommends that healthcare facilities reiterate to reprocessing staff the importance of careful cleaning and sterilization, and revisit protocols to snuff out the likelihood of infection.