What’s New in the Patient Safety World
December 2013
ECRI Institute’s 2014 Top 10 Technology Hazards
Each year ECRI Institute puts out its list of the top 10 health technology hazards. The ECRI Institute 2014 Top 10 Health Technology Hazards list is now out:
- Alarm hazards
- Infusion pump medication errors
- CT radiation exposure in pediatric patients
- Data integrity failures in EHRs and other health IT systems
- Occupational radiation hazards in hybrid ORs
- Inadequate reprocessing of endoscopes and surgical instruments
- Neglecting change management for networked devices and systems
- Risks to pediatric patients from "adult" technologies
- Robotic surgery complications due to insufficient training
- Retained devices and unretrieved fragments
Most of the entities on the list are repeats from prior years and we’ve discussed most of them extensively. It’s no surprise that alarm hazards are #1 on this year’s list. However, there are some that are new to the list this year: #5 Occupational radiation hazards in hybrid ORs, #7 neglecting change management for networked devices and systems, and #9 robotic surgery complications due to insufficient training. In addition, #10 retained devices and unretrieved fragments is a former list member that returned this year.
Hybrid OR’s are surgical areas into which advanced imaging
capabilities are brought. Unlike radiology suites or cath
labs where personnel are very familiar with risks of ionizing radiation,
personnel in these hybrid OR’s are less likely to be fully aware of the
radiation hazards. And it is the OR staff that are especially at risk to
radiation exposure. ECRI emphasizes the importance of radiation safety programs
that include training, shielding, and monitoring.
Hazard #7 “neglecting change management for network devices and systems” has become a real problem. This refers to changes made to one device or system having “downstream” consequences that are unintended and unanticipated. They cite as an example an instance where PC software upgrades resulted in loss of remote display capability of the facility’s fetal monitoring devices.
Hazard #9 deals with robotic surgery complications. The glow is coming off
robotic surgery. In the last few years we have seen more and more reports that
robotic surgery for certain conditions does not, as touted, result in either
better patient outcomes or fewer complications. In many cases, the widespread
rapid adoption of robotic surgery has resulted in practitioners doing
procedures before they have become sufficiently proficient with the new
technology. Recently it has also been suggested that there may be significant
underreporting of complications with robotic surgery (Cooper
2013).
One of the phenomena we’ve pointed out several times is that described by Charles Perrow in his classic book “Normal Accidents” (Perrow 1999) where he talks about how new technologies often simply “push the envelope”. He cites as an example how the introduction of maritime radar simply encouraged boats to travel faster and did little to reduce the occurrence of maritime accidents. Many of the hazards described by the ECRI Institute in their excellent reports on technology hazards are prime examples of that phenomenon.
References:
ECRI Institute. ECRI Institute 2014 Top 10 Health Technology Hazards.
https://www.ecri.org/Forms/Pages/2014_Top_10_Hazards.aspx
Cooper MA, Ibrahim A, Lyu H, Makary MA. Underreporting of Robotic Surgery Complications. Journal for Healthcare Quality 2013; Article first published online: 27 AUG 2013
http://onlinelibrary.wiley.com/doi/10.1111/jhq.12036/abstract
Perrow C. Normal Accidents: Living with high-risk technologies. Princeton, New Jersey: Princeton University Press, 1999
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