Alarms are the top health technology hazard for 2012, according to an ECRI Institute white paper.
The white paper, "2012 Top 10 Health Technology Hazards," judged the hazards of different health technologies based on its level of potential harm (Could it kill someone or cause serious injury?); likelihood of occurring; prevalence in the market (Would any harm that occurs affect many people?); and media coverage (Would you likely be under pressure to deal with the product quickly and conspicuously?).
Based on these factors, ECRI Institute's Health Devices System named the following top 10 health technology hazards:
1. Alarm hazards. Alarms can be hazardous for several reasons, including alarm fatigue, a lack of adequate alarm notification-and-response protocols and an inability to distinguish the urgency level of alarms. ECRI Institute suggests establishing an alarm management program that includes protocols to ensure each alarm will be recognized and responded to quickly.
2. Exposure hazards from radiation therapy and CT. Radiation therapy and CT are hazardous because errors can lead to ineffective tumor control and damage to normal tissue. ECRI Institute recommends ensuring adequate staffing levels and appropriate quality assurance and quality control procedures to minimize the risk of radiation to patients.
3. Medication administration errors using infusion pumps. Infusion pumps can harm patients due to illegible medication orders; incorrectly prepared drugs and solutions; and delivery of medication to the wrong patient. One way to mitigate this risk, according to ECRI Institute, is to view infusion pumps as part of an overall medication delivery system in which it may integrate with other information systems such as electronic medical records.
4. Cross-contamination from flexible endoscopes. Flexible endoscopes can be hazardous to patients when cleaning and disinfection/sterilization guidelines are not followed and when damaged or malfunctioning equipment is used. Healthcare providers should establish a specific reprocessing protocol for each flexible endoscope model in the facility's inventory, ECRI Institute says.
5. Inattention to change management for medical device connectivity. "Change management is a structured approach for ensuring that modifications to an existing system are performed in a controlled manner," according to ECRI Institute. A lack of change management can harm patients because of software anomalies, problems with interoperability between systems and degraded network performance. Changes to technology including hardware upgrades, software upgrades, security changes, new applications, new work processes and maintenance require assessment and controlled implementation to reduce the risk of harm, ECRI Institute says.
6. Enteral feeding misconnections. Enteral feeding, or delivery of nutrients into the GI tract via a tube, becomes hazardous when misconnections cause nutrients to be delivered elsewhere or inappropriate fluids to be delivered to the GI tract. ECRI Institute suggests using enteral pumps whenever possible and tracing lines from end to end when making an initial connection and reconnection.
7. Surgical fires. Surgical fires can occur when the surgical team does not understand the role of oxidizers, ignition sources and fuels in the operating room. ECRI Institute recommends healthcare providers communicate these risks to each member of the team and establish a surgical fire prevention and management program.
8. Needlesticks and other sharps injuries. Needlesticks and other sharp injuries can be hazardous because they can expose patients and caregivers to bloodborne pathogens, hepatitis C virus and HIV. Healthcare facilities need to assess their current practices, develop an action plan and implement the actions, such as ensuring all personnel are trained on preventing sharps injuries, according to ECRI Institute.
9. Anesthesia hazards due to incomplete pre-use inspection. Anesthesia equipment becomes hazardous when pre-use inspection is incomplete or inconsistent, causing providers to miss problems such as misconnected breathing circuits, ventilator leaks and empty gas cylinders. ECRI says providers should inspect the anesthesia equipment using the model-specific, manufacturer-prescribed full check before the first case of the day and use at least the manufacturer-prescribed abbreviated check for the model before each subsequent case.
10. Poor usability of home-use medical devices. Home-use medical devices are hazardous because they are often very difficult to use or very complex, according to ECRI Institute. The institute suggests ensuring the patient and caregiver can use the home medical device appropriately before prescribing any device.
EHR Association, iHealth Alliance Support Reporting Health IT-Related Incidents
Improving Cost-Efficiency, Safety in Hospitals via Imaging Clinical Decision Support
The white paper, "2012 Top 10 Health Technology Hazards," judged the hazards of different health technologies based on its level of potential harm (Could it kill someone or cause serious injury?); likelihood of occurring; prevalence in the market (Would any harm that occurs affect many people?); and media coverage (Would you likely be under pressure to deal with the product quickly and conspicuously?).
Based on these factors, ECRI Institute's Health Devices System named the following top 10 health technology hazards:
1. Alarm hazards. Alarms can be hazardous for several reasons, including alarm fatigue, a lack of adequate alarm notification-and-response protocols and an inability to distinguish the urgency level of alarms. ECRI Institute suggests establishing an alarm management program that includes protocols to ensure each alarm will be recognized and responded to quickly.
2. Exposure hazards from radiation therapy and CT. Radiation therapy and CT are hazardous because errors can lead to ineffective tumor control and damage to normal tissue. ECRI Institute recommends ensuring adequate staffing levels and appropriate quality assurance and quality control procedures to minimize the risk of radiation to patients.
3. Medication administration errors using infusion pumps. Infusion pumps can harm patients due to illegible medication orders; incorrectly prepared drugs and solutions; and delivery of medication to the wrong patient. One way to mitigate this risk, according to ECRI Institute, is to view infusion pumps as part of an overall medication delivery system in which it may integrate with other information systems such as electronic medical records.
4. Cross-contamination from flexible endoscopes. Flexible endoscopes can be hazardous to patients when cleaning and disinfection/sterilization guidelines are not followed and when damaged or malfunctioning equipment is used. Healthcare providers should establish a specific reprocessing protocol for each flexible endoscope model in the facility's inventory, ECRI Institute says.
5. Inattention to change management for medical device connectivity. "Change management is a structured approach for ensuring that modifications to an existing system are performed in a controlled manner," according to ECRI Institute. A lack of change management can harm patients because of software anomalies, problems with interoperability between systems and degraded network performance. Changes to technology including hardware upgrades, software upgrades, security changes, new applications, new work processes and maintenance require assessment and controlled implementation to reduce the risk of harm, ECRI Institute says.
6. Enteral feeding misconnections. Enteral feeding, or delivery of nutrients into the GI tract via a tube, becomes hazardous when misconnections cause nutrients to be delivered elsewhere or inappropriate fluids to be delivered to the GI tract. ECRI Institute suggests using enteral pumps whenever possible and tracing lines from end to end when making an initial connection and reconnection.
7. Surgical fires. Surgical fires can occur when the surgical team does not understand the role of oxidizers, ignition sources and fuels in the operating room. ECRI Institute recommends healthcare providers communicate these risks to each member of the team and establish a surgical fire prevention and management program.
8. Needlesticks and other sharps injuries. Needlesticks and other sharp injuries can be hazardous because they can expose patients and caregivers to bloodborne pathogens, hepatitis C virus and HIV. Healthcare facilities need to assess their current practices, develop an action plan and implement the actions, such as ensuring all personnel are trained on preventing sharps injuries, according to ECRI Institute.
9. Anesthesia hazards due to incomplete pre-use inspection. Anesthesia equipment becomes hazardous when pre-use inspection is incomplete or inconsistent, causing providers to miss problems such as misconnected breathing circuits, ventilator leaks and empty gas cylinders. ECRI says providers should inspect the anesthesia equipment using the model-specific, manufacturer-prescribed full check before the first case of the day and use at least the manufacturer-prescribed abbreviated check for the model before each subsequent case.
10. Poor usability of home-use medical devices. Home-use medical devices are hazardous because they are often very difficult to use or very complex, according to ECRI Institute. The institute suggests ensuring the patient and caregiver can use the home medical device appropriately before prescribing any device.
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