What’s New in the Patient Safety World

December 2015

ECRI’s Top 10 Health Technology Hazards for 2016



ECRI Institute has just published its annual Top 10 list for health technology hazards for 2016 (ECRI 2015). Our regular readers will not be surprised that alarm issues and opioid-induced respiratory depression are near the top of the list. But this year’s number one hazard is inadequate cleaning of flexible endoscopes before disinfection.


There has been a spate of reports recently of spread of deadly multi-drug-resistant organisms via inadequately cleaned and sterilized endoscopes. In particular, several fatal cases of carbapenem-resistant Enterobacteriaceae (CRE) were traced to inadequate cleaning of duodenoscopes. Disinfection and sterilization cannot eliminate bacteria that are covered with biologic debris. Therefore, adequate cleaning to remove such debris before the disinfection and sterilization steps are crucial. Duodenoscopes and other flexible endoscopes have complex designs that have lots of “nooks and crannies” that are difficult to clean.


As usual, ECRI Institute has done an excellent job of describing the hazards and making recommendations for organizations to address them. Here is the complete ECRI Top 10 list for 2016:


  1. Inadequate Cleaning of Flexible Endoscopes before Disinfection Can Spread Deadly Pathogens
  2. Missed Alarms Can Have Fatal Consequences
  3. Failure to Effectively Monitor Postoperative Patients for Opioid-Induced Respiratory Depression Can Lead to Brain Injury or Death
  4. Inadequate Surveillance of Monitored Patients in a Telemetry Setting May Put Patients at Risk
  5. Insufficient Training of Clinicians on Operating Room Technologies Puts Patients at Increased Risk of Harm
  6. Errors Arise When HIT Configurations and Facility Workflow Do Not Support Each Other
  7. Unsafe Injection Practices Expose Patients to Infectious Agents
  8. Gamma Camera Mechanical Failures Can Lead to Serious Injury or Death
  9. Failure to Appropriately Operate Intensive Care Ventilators Can Result in Preventable Ventilator-Induced Lung Injuries
  10. Misuse of USB Ports Can Cause Medical Devices to Malfunction


You can download ECRI Institute’s Top 10 Health Technology Hazards for 2016 for free at the ECRI site.






ECRI Institute. Top 10 Health Technology Hazards for 2016. ECRI Institute. November 2015





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