The following is the Top 10 Health Technology Hazards for 2017, a report from Health Devices and ECRI Institute.
1. Infusion errors can be deadly if simple safety steps are overlooked. ECRI Institute has investigated incidents of infusion errors involving pump or administration set failures. Other problems have occurred when staff unknowingly defeated a safety mechanism or the infusion programming was incorrect. Errors can lead to patient harm, particularly when they result in uncontrolled flow of medication, which is called “IV free flow.”
Staff could have averted the incidents if they had noticed signs of physical damage to infusion pump components, appropriately used the roller clamp on the IV tubing, and checked the drip chamber beneath the medication reservoir for unexpected flow.
2. Inadequate cleaning of complex reusable instruments can lead to infections. Outbreaks associated with contaminated duodenoscopes highlight the problem, but ECRI Institute also has received reports involving a variety of contaminated medical instruments that might have been used on patients. Most concerning are complex, reusable instruments such as endoscopes, cannulated drills, and arthroscopic shavers. These are difficult to clean, disinfect, or sterilize, and contamination is difficult to detect. The solution is for healthcare facilities to make reprocessing instructions available to staff and to ensure all steps are followed consistently.
3. Missed ventilator alarms can lead to patient harm. Staff might miss ventilator alarms when they become distracted by or desensitized to the number of alarms that activate. Alarms might not be communicated effectively to staff, leading to alarm notification failures. Preventing missed ventilator alarms poses unique challenges because collecting and analyzing ventilator alarm data can be difficult. Additionally, there are fewer options for supplementing ventilator alarms.
4. Undetected opioid-induced respiratory depression. The risk of giving patients opioids, including morphine, hydromorphone, and fentanyl, includes drug-induced respiratory depression. This condition can lead to anoxic brain injury or death if undetected, so spot checks of a patient’s oxygenation and ventilation are inadequate. Patients are at high risk if they also receive another drug with a sedating effect, suffer from sleep apnea, or receive more medication than intended. A prevention best practice would be to implement continuous monitoring of patients’ ventilation with recently tested and rated monitoring devices.
5. Infection risks with heater-cooler devices used in cardiothoracic surgery. The FDA has 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. Heater-cooler systems have been found to be a potential cause of nontuberculous mycobacteria (NTM) infections in heart surgery. Some patients have died from NTM infections. While it’s unclear precisely how the devices cause infection, it’s theorized that aerosolized water carried by air from the exhaust vents of contaminated heater-coolers is the cause.
6. Software management gaps put patients and patient data at risk. Facilities that fail to keep up with medical device software updates can delay their responses to safety alerts and become vulnerable to cybersecurity problems. For instance, mismanagement of software updates and alerts can affect patient care and safety by causing downtime or otherwise harming the performance of medical devices or interconnected systems. Mismanagement also can delay identification and implementation of key software updates that affect patient safety, and they can lead to lost, stolen, or inaccessible data.
7. Occupational radiation hazards in hybrid operating rooms. OR suites that contain built-in X-ray imaging systems can place clinicians working in these hybrid ORs at risk of exposure to ionizing radiation unless precautions are followed consistently. The risk is enhanced because employees in these ORs often lack adequate education about the risks of radiation exposure and how to prevent it. Also, the use of these X-ray imaging systems during complex procedures have placed an increasing number of specialists and staff at risk of radiation exposure during surgeries. Long-term exposure increases the risk of cancer, so surgery sites must provide OR-specific radiation protection training and take other action to minimize radiation exposure.
8. Automated dispensing cabinet setup and use errors may cause medication mishaps. Mistakes in setting up and using automated dispensing cabinets (ADCs) can create medication errors. ECRI Institute has received reports of incidents of the presence of the wrong drug or dose in an ADC pocket and the availability of high-alert drugs in unsecured areas of the cabinet. Also, needed drugs sometimes are not available. These types of problems can lead to severe patient injury. To prevent mistakes, surgery centers should plan carefully which medications to make available in a particular care area, where to place medication in a drawer to prevent one drug from being mistaken for another, and whether to restrict access to certain medications through locked pockets or other control mechanisms.
9. Surgical stapler misuse and malfunctions. Intraoperative hemorrhaging, tissue damage, unexpected postoperative bleeding, failed anastomoses, and other forms of patient harm can occur when surgical staplers are misused. Each year, the FDA receives thousands of adverse event reports related to surgical staplers. Severe injuries are infrequent, but do occur. To prevent harm, users should be familiar with the device operation and carefully select the appropriate staple size for the patient.
10. Device failures caused by cleaning products and practices. Devices can malfunction or fail prematurely when they’re cleaned with incompatible cleaning agents. For instance, the wrong cleaning agents can damage equipment surfaces and degrade plastics, causing device breakage. Also, improper cleaning techniques can damage seals, degrade lubricants, and cause fluid intrusion, damaging electronics, power supplies, and motors. There is no single ideal cleaner or process, so healthcare facilities should stock and use multiple cleaning products and train staff with device-specific cleaning methods.
- Top 10 Health Technology Hazards for 2017, a report from Health Devices and ECRI Institute, November 2016. http://bit.ly/2efnn76.